Harm Suicide and Risk PDF

Self-harm,
Royal College of Psychiatrists

suicide and risk:
helping people
who self-harm
Final report of a working group
Self-harm, suicide and risk: helping people who self-harm

© 2010 Royal College of Psychiatrists

Cover photograph: © 2010 iStockphoto/Natalya Filimonova
College Report CR158
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Scotland (SC038369). College Report CR158
Self-harm, suicide and risk:
helping people who self-harm

June 2010

London
Approved by Central Policy Coordination Committee: April 2010
Due for review: 2015
Disclaimer
This guidance (as updated from time to time) is for use by members of the Royal College of
Psychiatrists. It sets out guidance, principles and specific recommendations that, in the view of the
College, should be followed by members. Nonetheless, members remain responsible for regulating
their own conduct in relation to the subject matter of the guidance. Accordingly, to the extent
permitted by applicable law, the College excludes all liability of any kind arising as a consequence,
directly or indirectly, of the member either following or failing to follow the guidance.
Contents
Working Group 4
Executive summary 5
Part I: Understanding the problems and the people
1 Background 17
2 What is self-harm? 21
3 Self-harm and mental or physical disorders 25
4 Wider social concerns 29
5 Interventions 37
PART II: The public health agenda
6 The cost of self-harm 45
7 Strategies for the prevention of self-harm and suicide 47
8 A public health approach specifically to address self-harm 50
9 The role of the third sector 55
10 Research 58
Part III: Working with individual people
11 Introduction 63
12 Overarching themes 64
13 What do service users and carers want from services? 68
14 The College Members’ survey: skills and services 72
needed
15 Third-sector providers 95
16 Conclusions 96
Bibliography and references 97
Appendix I: Online survey of College Members 107
Appendix II: People who gave evidence to the Working Group 133
Appendix III: Pathways to suicide behaviour 135
Royal College of Psychiatrists 3

Working Group
C hair
John, Lord Alderdice Consultant Psychiatrist in Psychotherapy,
Northern Ireland
H onorary S ecretary
Dr John Morgan Consultant Psychiatrist, Leeds
Members
Ms Janey Antoniou Service User
Dr Jim Bolton Consultant Psychiatrist, South West London and
St George’s
Dr Tom Brown Consultant Psychiatrist, former Chair of the
Royal College of Psychiatrists, Scotland Division
Dr Cathal Cassidy Chair of the Royal College of Psychiatrists,
Northern Ireland Division
Dr Rowena Daw Head of Policy, Royal College of Psychiatrists
Dr Mick Dennis Consultant in Liaison Psychiatry for Older
People, Reader in Psychiatry, Swansea
Dr Kimmett Edgar Head of Research, Prison Reform Trust
Mr Joe Ferns Director of Policy, Research and Development,
Samaritans
Mr Adrian Fisher Service User
Professor Keith Hawton Oxford University Centre for Suicide Research
Ms Veronica Kamerling Carer
Professor Rory O’Connor British Psychological Society
Ms Lucy Palmer Programme Manager, Royal College of
Psychiatrists, College Research and Training Unit
Dr Gemma Trainor Psychiatric Nurse and Child and Adolescent
Mental Health Expert
Ms Melba Wilson* National Programme Lead, Mental Health
Equalities, National Mental Health Development
Unit
*Ms Sue Waterhouse, Deputy National Programme Lead, Mental Health Equalities, National Mental Health
Development Unit was a substitute for Ms Melba Wilson at most meetings and is an expert in her own right.
4 http://www.rcpsych.ac.uk
Executive summary
Self-harm is poorly understood in society even among those who in their

working lives as school teachers, pastors, social workers, housing officers,
police, prison officers and even nurses and doctors encounter people who
harm themselves. People who harm themselves are subject to stigma and
hostility. In contrast to the trends in completed suicide, the incidence of self-
harm has continued to rise in the UK over the past 20 years and, for young
people at least, is said to be among the highest in Europe. This high level
of self-harm among different age and social groups is a worrying feature of
our society.
The focus of this report is to enquire into and report on why people
harm and kill themselves and to consider the role (including the limits of
the role) that psychiatrists and other mental healthcare professionals play
in their care and treatment. The experiences and views of people who
harm themselves as well as those of their carers, health professionals and
third-sector workers are central to this enquiry. As there is much policy and
guidance on self-harm and suicide prevention, the report does not attempt
to retrace this same ground but rather examines the evidence of practice on
the ground, including the implementation of the National Institute for Health
and Clinical Excellence (NICE) guidelines on self-harm (National Collaborating
Centre for Mental Health, 2004).
This report is the second in the Royal College of Psychiatrists’
programme of work on the broad issue of risk. The College report Rethinking
Risk to Others was published in July 2008 (Royal College of Psychiatrists,
2008a) and a new Working Group was set up under the chairmanship of
John, Lord Alderdice, to examine risk, self-harm and suicide. This clinical
issue is an integral part of the role of the psychiatrist in ensuring the good
care and treatment of patients.
Our central theme is that the needs, care, well-being and individual
human dilemma of the person who harms themselves should be at the
heart of what we as clinicians do. Public health policy has a vital role to
play and psychiatrists must be involved and not leave these crucial political
and managerial decisions to those who are not professionally equipped to
appreciate the complexities of self-harm and suicide. But we must never
forget that we are not just dealing with social phenomena but with people
who are often at, and beyond the limit of what they can emotionally endure.
Their aggressive acts towards themselves can be difficult to understand
and frustrating to address, but this is precisely why psychiatrists need to be
involved to bring clarity to the differing causes for the self-destructive ways
in which people act and to assist in managing the problems for the people
concerned, including family, friends and professional carers, who sometimes
find themselves at the end of their tether in the face of such puzzling and
destructive behaviour.

The report is divided into three parts. In Part I, we give some

background information on self-harm in the UK and on understanding why
people harm themselves. In Part II, we examine some of the public health
policy issues, and in Part III we concentrate on the practice of healthcare
professionals and others who work with people who have harmed themselves
and are at risk of harming themselves, as evidenced particularly by a survey
and consultations with College Members and Faculties. The important role of
the third sector is also examined.
Part I: Understanding the problems and the people

For the purpose of this report we define self-harm as an intentional act of
self-poisoning or self-injury irrespective of the type of motivation or degree
of suicidal intent. Thus it includes suicide attempts as well as acts where
little or no suicidal intent is involved (e.g. where people harm themselves to
reduce internal tension, distract themselves from intolerable situations, as
a form of interpersonal communication of distress or other difficult feelings,
or to punish themselves.)
An act of self-harm is a not necessarily an attempt or even indicator
of suicide, indeed it can sometimes be a bizarre form of self-preservation.
Nevertheless it covers a wide spectrum of behaviour, with harmful physical
effects, and a person who repeatedly self-harms is at a higher risk of
suicide.
Self-harm is a behaviour, a manifestation of emotional distress. It is an
indication that something is wrong rather than a primary disorder. For each
person the contributing circumstances are individual. However, commonly
they include difficult personal circumstances, past trauma (including abuse,
neglect or loss), or social or economic deprivation together with some level of
mental disorder. A person’s self–harming behaviour may often be associated
with the misuse of drugs or alcohol. The rate of self-harm is higher among
women and girls than among men and boys, although completed suicide is
more prevalent among men and boys.
People of all ages and from all social and cultural backgrounds may
harm themselves but some groups are especially vulnerable because of
life experiences, personal or social circumstances, physical factors or a
combination of these elements. There is a higher incidence of self-harm
among prisoners, asylum seekers, veterans from the armed forces, people
bereaved by suicide, some cultural minority groups and people from sexual
minorities.
The assessment and management of a person who has harmed
themselves therefore requires a biopsychosocial approach which assesses
their problems, needs and in so far as is possible understands the
risks of further harm to this individual and provides a person-centred
management plan. Helping this person address their current and ongoing
problems with whatever help can be made available to them in their
context should be the key principle informing the care and treatment of
the individual.
Finally, we consider some of the interventions that have been found
effective for people who self-harm. This is brief, bearing in mind that the
findings of the new Cochrane review of interventions into self-harm are about
to be published but not available at the time of writing.
Executive summary
Part II: The public health agenda

In Part II we first consider the implications of the evidence about the nature
and causes of self-harm for public health strategies. Second, we look briefly
at the role of wider bodies than the health sector in dealing with self-harm
and suicide prevention.
The suicide prevention strategies in each of the countries of the
UK, including that first established in England, have been successful and
influential and should be continued, and improved. However, greater priority
needs to be given to self-harm whether as part of suicide prevention or as
a separate strategy, particularly in the English context. There is also an
opportunity for pooling of knowledge and expertise among those involved in
each of the suicide prevention strategies throughout the UK.
Given the social context of self-harm and the different populations at
risk, a self-harm strategy needs to be cross-departmental. It needs to include
the training of front-line staff in a range of sectors, and to ensure appropriate
and accessible public information and education. It should involve research
into the different aspects of self-harm and it should address emerging issues
relating to the internet. In particular, it should focus on drug and alcohol
strategies and social exclusion, especially at a time of economic crisis such
as the UK is experiencing now.
The third sector plays a vital role in policy and practice on self-harm
and suicide prevention from national charities such as the Samaritans to
small local organisations and interventions. National charities and many other
local and regional bodies provide support in different ways. They undertake
research and campaigns, operate telephone helplines and moderate website
forums, raise awareness and offer staff training, and provide practical services
for people who harm themselves, together with help and advice for carers.
Their links with service users and local networks are invaluable and their role
in any suicide prevention or self-harm strategies should be fostered.
Recommendations
•• Suicide prevention should remain a priority of public health policy in all countries in the UK. There
should be structures at national, regional and local level and mechanisms for the flow of information,
evaluation and best practice to ensure effective implementation. A partnership approach to
implementation should be adopted wherever feasible.
•• The needs of those at particular risk (including asylum seekers, minority ethnic groups, people
in institutional care or custody such as prisoners, people of sexual minorities, veterans and those
bereaved by suicide) should be actively addressed as part of this strategy.
•• A UK-wide forum should be established to bring together agencies from the four nations who are
involved in suicide prevention policy, research and practice.
•• The government department responsible for public health in each of the jurisdictions should lead a
cross-departmental strategy to raise awareness of self-harm, ensure appropriate training for front-
line staff in education, social work, prisons, police and other relevant agencies in dealing with self-
harm, and to help fund and promote research into suicide and self-harm. A partnership approach
to implementation should be adopted wherever feasible. The government department responsible
for public health should ensure that government websites including NHS Direct and the Department
of Health include authoritative, accurate, accessible and user-friendly information on self-harm for
service users, carers, family members and friends.
•• The monitoring of harmful internet websites should be included in this strategy.
•• Suicide prevention strategies and self-harm strategies should explore and strengthen the
relationships between third sector and statutory sector providers.

In Part II of the report we also mention the important role of other

bodies, including the professional bodies and the third sector. Professional
bodies such as the Royal College of Psychiatrists can play a useful role
as part of their public education function in providing authoritative and
accessible information for those who harm themselves, their carers, families
and friends, as well as basic information and toolkits for their staff and
colleagues.
Recommendation
•• The Royal College of Psychiatrists should collaborate with other mental health organisations and
professional bodies to ensure that helpful and user-friendly information is available for diverse
audiences and purposes.
Research
Finally, Part II addresses the need for research into self-harm. Although
suicide prevention has been the subject of much research in the UK and
elsewhere, self-harm as a distinct issue received much less attention until
recent years. As a result, people who harm themselves often do not get
the best care. Services and clinicians lack guidance as to what works, and
for whom, and commissioners lack evidence on outcomes to assist their
commissioning.
In England, research into self-harm undertaken as part of the suicide
prevention strategy and through the Oxford University Centre for Suicide
Research and other research organisations has added significantly to the
evidence base. Nevertheless, research is still much needed into all aspects of
the issue – epidemiological studies, investigations of the full range of causes
of self-harm, and, most importantly, effective interventions to treat and in
so far as it is possible to help prevent self-harm.
Recommendation
•• A combination of national government funding streams, medical research council/economic and
social research council, and charitable funds should consider research into self-harm as a funding
priority.
Part III: Working with individual people

The third part of the report examines the reported experiences of service
users who are in contact with health services; what they want and where
these services fall short. We then consider, from staff surveys, research and
from a survey and consultations with the College Members, Faculties and
Sections, what can be learned from the staff experience. Although there
is some good, even excellent practice reported to us, there are also clear
indications of fault lines and failures to meet the standards set by NICE
guidelines and professional practice. It is not possible for us to appraise
Executive summary
the extent of the problems, but it is clear that there is at times a significant
mismatch of what service users need, clinicians want and NICE recommends
on one hand, and what too frequently occurs in practice – even if though it
may be in a minority of cases.
Individual respondents to the College Members’ survey expressed
considerable concern and frustration about a range of issues concerning
the care that vulnerable people who are ill could expect to receive. This
was frequently linked to a lack of resources and pressures of busy work
places. Major themes included the lack of the necessary resources to
allow staff to undertake detailed assessments, or for the implementation
and follow-through of management plans, and the tendency to focus
on risk assessment whether to provide legal cover in the case of
misadventure or from a misguided notion that it is possible to predict the
future.
This all has immediate implications for patients’ recovery and for long-
term costs in the health and social care systems. Although most evidence
relates to emergency care, similar pressures apply to acute in-patient wards
and community mental health teams (CMHTs).
Presentation at hospital will often be the first time that the person who
is harming themselves will have had contact with the health service. Failure
to deal effectively with a person at this stage will have major repercussions.
It may discourage them from returning in a later crisis. It may mean they
become disengaged and lack the care and treatment they need. Such failures
are reported to be a major cause of hospital in-patient admissions. The
seriousness of this is often overlooked by hospital management.
Staff training
Families and friends may be frustrated and distressed by the actions of
the person who self-harms, but there is strong consistent evidence that
professionals can have similar responses. When the person needs humane
care and understanding they may also encounter hostility, disengagement or
bewilderment. Evaluations of staff training demonstrate its role in improving
their interactions with service users.
Recommendation
•• The Royal College of Psychiatrists works with colleagues in other health disciplines and other
relevant partners to develop a common curriculum on self-harm for front-line health professionals
and that Trusts and Health Boards provide time for staff regularly to receive this training and
professional support.
Respondents to the College survey expressed dissatisfaction with the

expertise of some members of their own profession and with other staff
(nurses, doctors, social workers, pediatricians, police and prison staff) in
dealing with and in undertaking assessments for people who have harmed
themselves (particularly those repeatedly harming themselves) or who are
suicidal. Many staff considered that they were not trained, or not adequately
trained or supported and supervised on psychosocial assessments.
The position is particularly acute in accident and emergency (A&E)
departments. It appears common for junior staff, especially junior doctors
and psychiatry trainees, to have responsibility – often at night and without

supervision – for assessing and managing the complex and potentially life-
threatening situations of people who have harmed themselves or attempted
suicide. The person may be under the influence of drugs or alcohol and the
question of their mental health as well as their physical and social needs
may be an issue. Work schedules, consequent on the European Working
Time Directive, were also said to be partly responsible for this development,
and young psychiatrists reported that they felt ill equipped for this work, as
well as overburdened and demoralised. Others reflected on the inadequate
assessments that they and others made because of lack of experience and
of time.
This situation is unacceptable by any reasonable standard. Experienced
clinicians need to be involved from the outset in these complex and chal
lenging cases to supervise and ideally to assess these patients. Lives may
be at stake and well-being certainly is. The Working Group agrees with the
views put to us that senior clinicians need to be enabled to provide a greater
involvement with patients who harm themselves, and this has significant
resource implications. Either more must be provided or it has to be redirected
from its current focus. Liaison psychiatrists with expertise with the different
groups of people, including adolescents and older people, should be available
both for A&E and general hospital wards. They should also be available to
provide supervision and training of junior and less experienced staff.
Recommendations
•• The Royal College of Psychiatrists should ensure that training in biopsychosocial assessment and
management of self-harm is a core competency for all junior psychiatrists. It should be an essential
(mandatory) component of prequalification training.
•• Trust and Health Board management should ensure that as part of their in-service training junior
doctors are exposed to people who harm themselves but with access to supervision on an immediate
and regular basis with senior staff. Staffing schedules should ensure that senior clinicians are
involved in supervising or managing cases of self-harm from the outset.
•• Commissioners of mental health services and Trust managements should make liaison psychiatrists
available for A&E and general hospital wards at all times, and they should be there to provide
training and support for colleagues dealing with self-harm.
Support for staff

Staff needs extend beyond regular supervision to proper ongoing support for
cases that can be personally distressing and professionally challenging for
staff to manage. It was put to us that the lack of support for staff reflects
the whole culture of some organisations where there is too little emphasis
on support, supervision and time for reflection. Introduction of reflective
practice would improve staff morale and knowledge and improve relations
between teams and departments.
Recommendation
•• For there be an improvement in the culture of practice to ensure that organisations support mental
health professionals and promote good patient outcomes for those who have harmed themselves.
Clinical staff should have sufficient support from colleagues who are available to them. Reflective
practice should be embedded into supervision and into organisational practice.
Executive summary
Risk assessments
Biopsychosocial assessments should be done with all patients who self-harm
(as per NICE guidelines; National Collaborating Centre for Mental Health,
2004). A central purpose of psychosocial assessment is to identify a patient’s
needs and the risks to them and to devise a management plan to address
these issues. The management plan lays the foundation for future long-term
care, which in the case of people who harm themselves requires long-term
thinking and should often involve multiple partners.
The College Members’ survey informed the enquiry on the practice of
assessments, including the important issue of the role of risk assessments.
Risk assessment is a core function of medical practice. However, sustained
by an overvalued view of predicting the future and a perceived culture of
blame, Trusts need to protect against an overdue cloud of litigation threat,
which together with the increased role of junior staff tends at present
to dominate practice. This is despite the acknowledged fact that risk
assessment per se has a very limited, and short-term, predictive power of
a person’s future risk. As they had done for the previous College Report
on risk (Royal College of Psychiatrists, 2004), respondents voiced their
dissatisfaction with current practice, in particular the continued use of long
locally developed risk assessment tools that lacked validity, encouraged a
tick-box mentality, distracted staff from their work with vulnerable people,
devalued engagement and impaired empathy. This practice is contrary to
recommendations in the NICE guidelines.
Recommendation
•• Locally developed risk assessment tools should be abandoned. All risk assessment tools should be
evidence-based and widely validated. Where risk assessment tools are used they should be seen
as part of routine biopsychosocial assessment and not as a separate exercise.
Psychosocial assessments
There are problems too with psychosocial assessments. People may be
discharged with either a superficial assessment or none at all after an episode
of self-harm; most critically that means they are discharged without an
opportunity to be listened to and to listen, for their personal and medical
situation to be understood and the need for future management considered.
There needs to be a rebalancing of a clinician’s effort and time, with
less attention to risk assessment and greater attention given to ensuring
a full biopsychosocial assessment that reviews holistically the needs of the
person and provides a carefully thought-out future plan.
Recommendations
•• People attending hospital after an episode of self-harm should all receive a biopsychosocial
assessment, done in accordance with the NICE guideline, by a clinician with adequate skill and
experience.
•• Psychiatrists assessing people who have harmed themselves should undertake a comprehensive
psychiatric history and mental state examination together with an assessment of risk. In that way
risk and needs assessments should be more closely tethered.

Discharge and continuity of care

Pressure to discharge patients from A&E departments and pressures on beds
means that sometimes people are discharged too soon after an episode of
self-harm or a suicide attempt. Furthermore, contrary to NICE guidelines,
patients are often discharged from the A&E department with no or minimal
communication to primary care. Some vulnerable people also discharge
themselves because of excessive waiting time involved in A&E attendance.
Care pathways are not always in place. Individual management plans
may simply respond to the immediate concerns rather than embrace a
longer-term perspective. The longer-term management of self-harm appears
to vary in quality with the problems of fragmentation of services, duplication
of assessments and people being lost to the system being cited to us as of
great concern. Lack of follow-through also arises because of communication
problems between different teams and staffing shortages, especially over
the summer period. There is no clear pathway for self-harm in some Trusts
or Health Boards. All of these factors mean that the requisite standard of
care was not being provided. These issues must be taken up in developing
the new NICE guidelines.
At a time of changes in service design, heightened pressures on
resources and new evidence about what works for people who harm
themselves, there is clearly a need for new practice-based guidance for
clinicians of all professional backgrounds. Clinical care pathways need to
be reassessed and recommendations made that reflect these new factors,
identify efficiencies, duplication and waste but also ensure that long-term
care of people who need it is at the heart of what is done.
Recommendation
•• The College Report Assessment Following Self-harm in Adults (Royal College of Psychiatrists, 2004)
should be updated, reflecting findings in this report, relevant NICE Guidelines and other policy and
practice-based developments.
Psychological therapies
Evidence-based therapies, including problem-solving therapy and cognitive–
behavioural therapy (CBT), have been proved beneficial for some people
who harm themselves. Many respondents to the College Members’ survey
expressed frustration that appropriate psychological therapies were not
available, despite being recommended by the NICE guidelines.
Recommendation
•• Mental health commissioners should take more account of the needs of people who harm themselves
and ensure that evidence-based psychological therapies are available for individuals who need them.
Research needs to be funded into relevant therapies to improve the evidence base.
Particular groups of people

We also report on three particular issues that were raised most frequently to
the Working Group by College Members and others as part of this enquiry.
Executive summary
A perceived neglect for people who repeatedly harm themselves and

for those with a diagnosed personality disorder was a common theme. It is
important that these issues be fully considered as part of the development of
a new NICE guideline. We also considered the merits of dedicated self-harm
services and urge this to be a subject for future research.
Recommendation
•• As part of our recommendations on research, we highlight the need for an examination of different
models of care for people who repeatedly harm themselves with the effectiveness of dedicated self-
harm services as part of such an enquiry.
Given the ageing population and the previous comparative neglect

of services for older people, and given also that self-harm is a growing
phenomenon with older people and the risk of completed suicide is higher in
this age group, the Working Group insisted that special consideration needs
to be made of the needs of older people.
The College Faculty of Old Age Psychiatry also said that there needed
to be a recognition by services that they should: actively treat depression
in later life; have a low threshold for referral to specialist services for older
people; end the discrimination in their access to services in general; and not
underestimate the seriousness of self-harm and suicidal behaviour in later
life.
The Working Group strongly endorses these views.
Prisoners and those in forensic facilities are particularly vulnerable to
self-harm and suicide. We welcome the work that is being taken forward to
improve their situation in England.
Recommendation
•• The four approaches – diversion from the criminal justice system for those with mental illness;
equivalent ‘in-reach’ care for prisoners as for those in the general population; timely and speedy
prison transfer for those with severe mental illness; and effective training for prison staff – be
energetically pursued in future work throughout all the countries of the UK.
The third sector

The third sector plays a constructive and at times crucial part in the well-
being, care and treatment of those who harm themselves. For many people
they are the first or only point of call. Their experience, knowledge and skills
are immense. Relations with the third sector have not always been fostered
by those who work in statutory services and are still underused.
Recommendation
•• Psychiatrists and other mental health professionals should acknowledge the crucial contribution
of the third sector in dealing with self-harm and suicide. The Royal College of Psychiatrists and
mental health professionals in the statutory sector should collaborate with them, explore ways
of partnership working and each should have the opportunity to learn from the experience of the
other sector.

Appendix I gives a summarised account of the findings of the College

Members’ survey. A full version is available on the College website (www.
rcpsych.ac.uk/risktoself).
Part I
Understanding the problems
and the people
1. Background
Over the past decade the assessment and management of risks posed by
people with mental illness to others and to themselves have preoccupied
policy makers and services in mental health. This originally stemmed largely
from public concern about some high-profile cases where harm had resulted
from homicidal actions by people with a mental illness. This resulted in
mandatory homicide inquiries focusing on risk to others. The Royal College
of Psychiatrists decided to embark on a programme of work on the broad
issue of ‘risk’, but to include risk to self as well as risk to others. The College
report Rethinking Risk to Others was published in July 2008 (Royal College
of Psychiatrists, 2008a), and a new Working Group was set up under the
Chairmanship of John, Lord Alderdice, to examine risk, self-harm and
suicide.
Our approach
In contrast to the trends in completed suicide, the incidence of self-harm has
risen in the UK over the past 20 years and, for some groups, is said to be
among the highest in Europe. This high level of self-harm among different
age and social groups is a worrying feature of our society.
The phenomenon of self-harm is not well understood within the
community or even among some professionals who encounter it in their
work. People who do harm to themselves are more likely to be subject to
stigma and hostility than to be helped to understand why they are harming
themselves. Self-harm is of immediate concern to consultant psychiatrists
who regularly see people in severe distress who have done or are at risk
of doing harm to themselves or even taking their lives. The focus of this
report is to give an account of why people harm and kill themselves and to
consider the role (including the limits of the role) of psychiatrists and other
mental healthcare professionals in engaging with people who find themselves
behaving in these self-destructive ways. The experiences and views of people
who harm themselves are a very important element of this enquiry.
The Working Group were mindful of the excellent academic research
work, government policy development, and health and social care practice
that is already taking place. This includes the suicide prevention strategies
across the UK and the existing NICE guidelines on self-harm (National
Collaborating Centre for Mental Health, 2004) together with the new
NICE guidelines under development (http://guidance.nice.org.uk/CG/
WaveR/82). The Group therefore decided to concentrate on the barriers to
implementation of the policies that are already in place, and to highlight any
important gaps or problems of understanding that emerged in our study.

We were able to take into account research being done within the
College and by external UK research bodies, including the Oxford University
Centre for Suicide Research, as well as the work of mental health charities,
service user groups and the findings of our College reports on risk to others.
We have not attempted to cover international research.
We decided that although this report should take account of all this
evidence, we should not try ourselves to propose clinical standards and
assess the effectiveness of clinical interventions, but would concentrate on
understanding the experience of the person who had harmed themselves, as
well as their carers and those who were charged with trying to help them,
and how services might better help them.
The Working Group settled on the following terms of reference.
To assess what contribution psychiatrists can make to understanding
why people harm themselves, and when and how we might contribute
to the prevention and treatment of those who harm themselves, and
the prevention of suicide.
To investigate the barriers facing psychiatrists and other mental
healthcare professionals in the implementation of relevant policies,
services and treatments.
To investigate the interaction of psychiatrists with other healthcare
professionals, service users and families, and to give due care and
attention to the experience of service users and carers.
To investigate the role current models of risk assessment and risk
management play in the prevention and treatment of self-harm and the
prevention of suicide, and whether and how they might be improved.
In doing this work the Working Group directed itself to pay attention
to the importance of the differences between individuals, population groups
and contexts. Over the course of our deliberations certain areas of interest
emerged from these broad themes and they have formed the basis of the
report. We have concentrated on self-harm as a subject in its own right as
well as when it may be a precursor to suicide.
Process
The Working Group met throughout 2009 and early 2010 and took evidence
in person and in writing from selected experts. (A list of their names appears
in Appendix II). Other experts were interviewed individually. The Group
was also most grateful for the written submissions provided by College
Faculties and the Scottish, Northern Irish and Welsh Divisions, and also for
the comments on drafts of the report from College Faculties, Divisions and
Special Interest Groups. The College Service Users’ Recovery Forum and the
Carers’ Forum contributed their valuable views and were consulted in the
preparation of the report.
College Members’ survey

A survey was sent to 9750 College Members with a working email address
(in the UK and overseas). It is reproduced in Appendix I. A total of 1540
Background
College Members completed the survey. The results form a key part of this
report. Although the results are not statistically representative of the wider
College membership, the results provide important insights into the views
and opinions of a comparatively large number of College Members. The
survey concentrated on risk assessments and on other issues covered by
NICE guidelines (National Collaborating Centre for Mental Health, 2004).
Responses cover different aspects of, and provide different angles on, the
quality of patient care, particularly in acute services.
Structure of the report

In Part I of the report we give some background information on self-harm
in the UK and on understanding why people harm themselves. In Part II,
we examine some of the public health policy general issues, and in Part III
we concentrate on the practice of healthcare professionals and others who
work with people who have harmed themselves and are at risk of harming
themselves, as evidenced particularly by the Members survey’. We conclude
with making recommendations for improvements.
We have included many quotations from patients, carers and healthcare
professionals in order to ground the report as much as possible in the
experience of the people concerned. These are generally given in italics and
quotation marks for ease and clarity of identification. Some of the quotations
are from other published research or reports.
We have kept references to a minimum, for ease of reading and have
included a bibliography of works consulted. The authors of this report are
Rowena Daw and Lord Alderdice, with contributions from other members
of the Working Group. The Working Group is deeply grateful to Dr Daw in
particular for the enormous amount of work that she did in drawing the
material together and writing the text. We are also grateful to Dr Martin
Skipper who contributed to the research and provided secretarial support and
to Mr Chris Fitch, Research Fellow in the College Policy Unit, who undertook
and analysed the College Members’ survey and compiled the report in
Appendix I.
Previous related College Reports

The College has been engaged in previous years with the issues of harm
to self and others and the assessment of risk. This report is intended to
complement and build upon, but not to replicate, these previous College
Reports and the quality standards as described below.
Assessment Following Self-harm in Adults, Council Report CR122
(Royal College of Psychiatrists, 2004). This report identifies consensus
standards for assessment following self-harm. It identifies the
competencies expected of both generalist and specialist staff in all
hospital and community settings.
Better Services for People who Self-Harm: Quality Standards for
Healthcare Professionals (Royal College of Psychiatrists, 2006). This
best practice guideline incorporates the NICE guidance and includes
other standards and current legislation from the Royal College of

Psychiatrists, the Faculty of Accident and Emergency Medicine, and

the Department of Health. It lists principles for all staff regardless
of their profession and describes best practice along a common care
pathway, allowing professionals to apply these standards directly to
patient care.
Rethinking Risk to Others in Mental Health Services, College Report
CR150 (Royal College of Psychiatrists, 2008a). This report examines
the concepts and practice of risk assessments for risk to others and
makes recommendations for future policy and practice.
2. What is self-harm?
Problems of definition
Given the varying types of self-harm, the different contexts in which it occurs
and the different motives and meaning for the individual concerned, defining
self-harm is not straightforward. The NICE guidelines (National Collaborating
Centre for Mental Health, 2004) use the short and broad definition:
‘Self-poisoning or self-injury, irrespective of the apparent purpose of
the act.’
The service users’ National Self-Harm Network (NSHN; 1998)

presented an alternative description:
‘Self-injury is frequently the least possible amount of damage and
represents extreme self-restraint.’
Some of the people consulted as part of this report expressed their

wish for a single definition that would be clear and acceptable for everyone
– service users, carers, health and social care professionals and the public
alike; however, self-harm is not a particular disorder or even a particular type
of behaviour. Indeed there is a real danger that we lose sight of the fact that
this is about people in distress. Worst of all, these people, who are already in
distress (no one harms themselves because they are happy), are diminished
further by being referred to as ‘self-harmers’ or ‘cutters’. Such terminology
prevents those who use it from trying to understand the complexity of what
is going on for those with whom they are working. We have avoided such
terms in this report, except where we are quoting directly from other work
when for the sake of accuracy we use the terms in the original published
documents.
In this report we address under the term ‘self-harm’ intentional acts of
self-poisoning or self-injury irrespective of the type of motivation or degree
of suicidal intent, a definition that is used widely within Europe and elsewhere
(Hawton et al, 2007a). Thus it includes suicide attempts as well as acts
where little or no suicidal intent at all is involved, for example when people
harm themselves as a form of interpersonal communication of distress or
other difficult feelings to reduce internal tension or to punish themselves.
Self-harm can take many forms. The most common form of self–injury
is cutting (with a variety of implements and degrees of severity). There
is some evidence that cutting is more repetitive than other forms of self-
harm, and that it may not be as predominantly a female activity as is
commonly thought (Lilley et al, 2008). Other forms include burning, hanging,
strangulation, scratching, banging or hitting body parts, and mutilation of
parts of the body or interfering with wound healing. A relative increase in the

incidence of hanging over the past few decades has been reported (Hawton
et al, 2008).
Self-poisoning is the intentional use of more than prescribed or
recommended doses of any drug and includes poisoning by non-ingestible
substances, overdoses of recreational drugs and severe alcohol intoxication
where this seems to be intended as an act of self-harm. People may switch
methods of harming themselves over time. Although it is likely that the
incidence of self-poisoning is lower in the population that does not seek
medical care, it is more frequently encountered in the health services than
self-injury.
Substance misuse through excessive alcohol or drug consumption,
eating disorders, physical risk-taking, sexual risk-taking, self-neglect and
misuse of prescribed medication are sometimes labelled ‘indirect self-harm’
and one could consider self-neglect as another form of self-harm. Indeed,
when people who repeatedly harm themselves through cutting or taking
overdoses are helped to overcome these behaviours, eating disorders
or other self-damaging problems may emerge. For the purposes of this
report we limit our discussion to self-injury and self-poisoning as discussed
above.
Incidence in different age groups and gender issues

Suicide is a significant cause of death. In Britain, suicide is the third largest
contributor to premature mortality (after heart disease and cancer) (World
Health Organization, 2000). Although the suicide rate is now the lowest it
has ever been in the UK (National Mental Health Development Unit, 2009),
in 2007 there were still 7.9 suicides per 100 000 people, which translates into
about 4000 incidents per year.
Younger people are more likely to die by suicide than older people.
Statistics show that in 16- to 24-year-olds, 5% have attempted suicide,
compared with 2% of 65- to 74-year-olds. However, the rate among people
over 85 rises again. There are not only age-group differences in suicide
rates, but also differences between males and females. According to the
World Health Organization (WHO) Global Burden of Disease: 2004 Update
report (World Health Organization, 2008), men are five times as likely to die
by suicide as women. Of people in the UK who die by suicide, only about
25% were in contact with mental health services in the 12 months before the
suicide, although it is generally acknowledged that most had a diagnosis of a
mental disorder at the time of their death (Bertolote & Fleischmann, 2002).
In some studies, the rate of a diagnosed mental illness of those who have
killed themselves has been found to be more than 80% (Arsenault-Lapierre
et al, 2004; Fleischmann et al, 2005; McManus et al, 2009).
The UK has one of the highest self-harm rates in Europe, reported at
about 400 per 100 000 people (Horrocks et al, 2002). It has been estimated
that there are 170 000 self-harm presentations at hospitals each year in
England (Kapur et al, 1998) and self-harm has been quoted as one of the
five top causes of acute hospital admissions, but this greatly underestimates
the problem since many people do not attend hospital. As with suicide,
younger people are more likely to self-harm than older individuals. Of those
who present at hospitals, two-thirds of patients who self-harm are under
the age of 35 years and two-thirds of people in this age group are female.
Overall, women are more likely to self-harm than men; one study recorded
What is self-harm?
that females are in fact up to five times as likely as males to display such
behavior (Fox & Hawton, 2004).
People who self-harm repeatedly are at a high and persistent risk of
suicide (Owens et al, 2002; Hawton et al, 2003). One recent study found an
approximately 30-fold increase in risk of suicide, compared with the general
population, among those they studied; the rate was substantially higher for
female patients than for male patients. Suicide rates were highest within the
first 6 months after the index self-harm episode (Cooper et al, 2005).
Motives and causes

People are individuals. People who harm themselves not only do so in varying
ways, but the background to their behaviour and their motivations differ as
well. Self-harm is a manifestation of emotional distress. It is not necessarily
the case that an act of self-harm is an attempt or even indicator of intent
to die by suicide (Swales, 2005); indeed, it can be seen as a form of self-
preservation. An individual may be strongly motivated to end their life or
may be ambivalent. Having taken what they see as a lethal overdose, the
person may have informed someone of what they have done.
‘I don’t see it as a prelude to suicide; I see it as a survival thing.’
An act of self-harm is often described by service users as a coping

mechanism or as a distraction that brings relief, in most cases accompanied
by a complex set of feelings, self-disgust and shame also being among them
(Klegg, 2005; Chapman et al, 2006). Studies interviewing people who have
harmed themselves show remarkable consistency, at least for repeated
self-harm, with the desire being to manage unbearable pain or unbearable
situations, including the wish to die (Hjelmeland et al, 2002; Mental Health
Foundation, 2006; O’Connor et al, 2009a).
‘In some ways it gave me control over the pain I felt, rather than having
it inflicted on me by someone else, somehow inflicting harm on myself
as I say, got me through the other afflictions […] it was just helping me
through life in general.’
In a study of people who self-injure and have a diagnosis of borderline

personality disorder, about 90% indicated that they felt less angry and
anxious and more peaceful after self-injury (Klonsky, 2007). Similarly,
adolescents who self-harm, with no history of a psychiatric disorder, have
reported mental states such as angry, depressed, lonely and frustrated
before self-harm and these were said to be diminished afterwards (Klonsky,
2007). Participants in one study also reported that self-harm helped them
to function better, helping them to stay connected with reality and ‘afloat in
the ebb and flow of day-to-day life’ (Csipke & Horne, 2008).
For many people self-harm, especially self–injury, remains a secret
activity that persists for a period until circumstances change or ‘I grew out of
it’. Sometimes with the help of medication or therapy the urge diminishes, is
better controlled or alternative means are found to channel distress. Young
people may have particular difficulties with disclosure of self-harm. In partic
ular, they fear that by disclosing their self-harm they will lose control to others
– family members, the school and other professionals. Their lack of control
can exacerbate their self-harm (Mental Health Foundation, 2006). Trusting
others to keep their problems confidential is a cause of great anxiety.

It follows that many such people do not come to the attention of any
services. This has important implications for public health strategies and is
discussed below. Self-harming is a key health problem among adolescents.
It may not always indicate ‘severe pathology’ but rather a period of ‘transient
distress’ (Hawton et al, 2006). In a recent small community study, the
authors compiled a comparison of motives chosen by young people who
either injured themselves or overdosed/poisoned themselves to explain their
acts (Hawton et al, 2006) (Table 2.1).
Table 2.1 Motives chosen by young people to explain reason for self-injury
Motive Self-cutting, % (n/N) Self-poisoning, % (n/N)
Escape from a terrible state 73.3 (140/191) 72.6 (53/73)
of mind
Punishment 45.0 (85/189) 38.5 (25/65)
Death 40.2 (74/184) 66.7 (50/75)
Demonstration of desperation 37.6 (71/189) 43.9 (29/66)
Wanted to find out if someone 27.8 (52/188) 41.2 (28/66)
loved them
Attention seeking 21.7 (39/180) 28.8 (19/66)
Wanted to frighten someone 18.6 (35/188) 24.6 (16/65)
Wanted to get back at 12.5 (23/184) 17.2 (11/64)
someone
Similar motivation has been expressed in studies across different

age groups, including a study involving 1000 people (88% females) aged
between 12 and 59 years (Csipke & Horne, 2008). By contrast, self-harm
among older people has a distinct and different profile. Interviews with older
people consistently show a suicidal intent behind an act of self-harm (Dennis
et al, 2007).
A person who regularly harms themselves may have different reasons
on different occasions when they engage in these actions; indeed their
motives can evolve over time. At times, a person’s intentions may be
confused or may be unknown by them or by others.
Much self-harm is repeated and can become habitual or even addictive
(Csipke & Horne, 2008).
‘After a while it just feels like routine and a way to keep your mind in
check.’
Self-harm can also have a contagious effect, particularly with young

people (Hawton et al, 2002). Young people in residential care have been
reported to be at greater risk of self-harm than those living in the community
(Mental Health Foundation, 2006). We consider in the following chapter
the particular issues of prisoners and people with intellectual disabilities in
care.
3. Self-harm and mental or physical
disorders
Mental illness
‘Self-harm is not an illness, but is more or less dangerous behaviour that

should alert us to an underlying problem, difficulty or disorder.’ (National
Collaborating Centre for Mental Health, 2004: p. 16)
As yet we have not mentioned formal psychiatric illness regarding self-

harm. This is not because it is not an important cause in some people, but
because it is likely that the majority of those who harm themselves do not
have a formal psychiatric illnesses. One of the difficulties in assessment is
that unless the assessor is appropriately trained and has the opportunity
to conduct a proper psychiatric history with its inherent biopsychosocial
enquiry and diagnostic assessment, there will be no differentiation between
people who have harmed themselves as a way of dealing with unhappiness
and other emotional disturbances, which are directly related to and to some
extent an understandable reaction to external circumstances, and those
whose self-damaging behaviour is attributable to a psychiatric disorder and
a resultant disturbed mental state.
Making such a differentiation is important not only in assessing risk but
also in deciding a future management plan. For example, where someone is
harming themselves in reaction to unhappy life circumstances it would seem
reasonable to assist them to address their problems in a less self-destructive
way. In this context, cognitive–behavioural therapy (CBT), may be helpful
as a kind of protocol for how to address problems of difficult feelings (e.g.
anxiety or depression/unhappiness). It can function as a form of coaching
or guidance towards natural healthy problem-solving. Indeed, many people
could use the techniques of CBT to assist them in addressing problems of
ordinary living.
For those who have more fundamental disorders of personality or who
have a formal psychiatric illness, the management or treatment approach
may or may not require CBT and/or its elements but will most likely require
other biopsychosocial interventions – medication, other psychotherapies,
assistance with arrangements for living, containment and protection from
harm, etc. In other words, if the self-harming behaviour is attributable to a
psychiatric illness then that illness needs to be identified and treated.
There are strong links between self-harm and borderline personality
disorder (Klonsky, 2007), but individuals with other diagnoses such as
major depression, anxiety disorders, substance misuse, eating disorders,
post-traumatic stress disorder (PTSD), schizophrenia and other personality

disorders are also at a high level of risk. The rates of a diagnosed mental
disorder are higher among those who persistently self-harm. (One study
of patients who repeatedly self-harmed found the prevalence of mental
illness and personality disorder to be 90% and 46% respectively (Haw et al,
2001).)
In one study of people presenting at general hospitals involving 1108
individuals (a third of whom were assessed by mental health specialists),
probable depression was identified in 29%; alcohol or drug misuse in 32%
(a further 9% were alcohol dependent); anxiety/stress-related disorders in
13%; a severe mental illness in 7%; and a further 4% were diagnosed with
personality disorders (Dickson et al, 2009). Four per cent were identified as
having no psychiatric disorder evident at time of assessment.
Across all age groups and for both men and women, mental illness,
including depression, bipolar disorder, schizophrenia, personality disorders
and childhood disorders, has been established as a risk factor for suicide
(McLean et al, 2008). Suicide is a major cause of death for women who
die during pregnancy and after giving birth; this is strongly associated with
mental disorder (National Collaborating Centre for Mental Health, 2007a).
Given the high rate of psychiatric disorder among people harming
themselves and especially in those taking their lives, it is a very important
responsibility of anyone assessing the needs of a person who has harmed
themselves that they can and do identify whether or not the person is
suffering from an identifiable psychiatric illness.
People with intellectual disabilities

The nature and extent of self-harm among people with intellectual
disabilities is not well understood, although it is believed to be not
uncommon (Lovell, 2008). A recent review of the views of people with
intellectual disabilities and their families has stressed the importance of
acknowledging self-injury as an issue in its own right, and for it to be taken
seriously. They report that too often self-harm is dismissed as ‘challenging
behaviour’ and the specific personal distress underlying it not addressed
(Heslop & Macaulay, 2009). Estimates of self-harming behaviour in different
populations of people using learning disability services vary (range 1.7–
24% across studies) (Deb, 1998; Duperouzel, 2004; Allen et al, 2007;
Cooper et al, 2008a). Self-injury has, however, been found to be more
serious in people with severe intellectual disabilities. Research has identified
a narrower range of contributing factors than in the general population,
including genetically determined syndromes and other physiological factors
as well as autism.
The fact that the person may be living in an institution that is
an impoverished, abusive or neglectful environment has been found,
unsurprisingly, to contribute directly to their self-harming behaviour. As
with young people in care, people with intellectual disabilities have also
cited their disempowering circumstances and having little control over their
environment.
‘They treat us like kids … and its very horrible.’ (Heslop & Macaulay,
2009)
They indicated the circumstances leading to their self-harm. These

included being bullied and remembering past traumas but also being irritated
Self-harm and mental or physical disorders
by other residents, having a lack of personal space, too little autonomy, too
much noise and not being free to go out when they wished.
Drug and alcohol issues and dual diagnosis

The relationship between drug and alcohol misuse and self-harm is a growing
trend that should be a matter of concern for its impact at all levels – on the
individuals and their family and friends, on the care services and on the cost
to public finances. People who harm themselves while under the influence of
alcohol pose distinct problems for services.
People who have – or are recovering from – drug and alcohol problems
are at a significantly greater risk of self-harm and suicide than the general
population (National Mental Health Development Unit, 2009). (The primary
focus of research is the use of illicit drugs, particularly dependence on
heroin and/or crack cocaine, but there is also evidence of links between
self-harm and suicide and other forms of drug use, including stimulants,
and prescription drugs.) The National Confidential Inquiry into suicide and
homicide by people with mental illness (Appleby et al, 2008) found that the
majority of the suicide cases it investigated (58%) were alcohol dependent,
39% were drug dependent and 29% heavily misused both.
In people who have a pre-existing tendency to self-harm or suicide the
risk of self-harm can be increased if they have alcohol and drug problems,
both as a result of intoxication and in the psychological withdrawal phase.
In some circumstances, the use of alcohol or drugs acts as a form of self-
medication, and the risk of suicide and self-harm can increase in the short-
term when people begin to address their substance problem. These issues
are acknowledged in clinical guidelines (Department of Health (England) and
the devolved administrations, 2007; National Collaborating Centre for Mental
Health, 2007b). This has implications for assessment, treatment planning
and the management of the withdrawal process. Drug misuse and the pains
of untreated withdrawal are also significant factors in the heightened risk of
suicide for people in prison. Ruth Wyner, a former drug services worker who
spent time in prison, has written:
‘Sending addicts to prison re-ignites old traumas, and adds to the terror,
the despair; the fragile self disintegrates further. … In fact, the trauma
of prison can open up those old buried traumas and bring them back
to consciousness. … Alienated and angry, depressed and despairing;
however offenders deal with their problems, being in prison tends to
make them worse.’ (Wyner, 2004)
There has been an increase in drug and alcohol misuse in the general
population over the past few decades. The per capita consumption of
alcohol has, for example, risen by 50% since 1970. The UK also has the
highest prevalence of drug misuse in Europe. The UK death rate from acute
poisoning with illicit drugs has more than doubled since 1993. According to
some evidence (Harris & Barraclough, 1997; Weaver et al, 2002), problem
drug use is more common in men than in women, among young people,
among the socially disadvantaged and in those with alcohol problems.
There is also evidence of self-harming behaviour being more regularly
associated with alcohol in women. Drug misuse related to self-harm has also
risen for women, and this has been particularly related to a suicide attempts
(Haw et al, 2005).

‘I used to get just stressed out and think “right, hit the bottle” … at first
I’d feel a bit better, more relaxed and then … I’d end up feeling like a
volcano where I’d explode and I’d either go and hit out at somebody or
hit back on myself because I can’t cope with this and that’s when I’d hit
myself hard.’ (Sinclair & Green, 2005)
Most people who misuse drugs and alcohol have a mental health
problem. According to recent research (Wagner et al, 2000), 74.5% of users
of drug services and 85.5% of users of alcohol services had mental health
problems and, conversely, 44% of mental health service users reported drug
use and/or were assessed to have used alcohol at hazardous or harmful
levels in the past year. People in drug and alcohol services with comorbid
mental health problems have a poorer prognosis, higher rates of relapse,
increased hospitalisation and higher suicide rates. These factors have
implications for public health, for treatment of the individual patient and for
inter-agency working, which will be considered later in this report.
Self-harm and physical health

Aside from the obvious danger of death, self-harm and suicide attempts
can be seriously detrimental to an individual’s long-term physical health, if
they survive. Paracetamol poisoning is a major cause of acute liver failure
(Haw et al, 2005). Self-cutting can result in permanent damage to tendons
and nerves, not to mention scarring and other disfigurements. The NICE
guidelines on self-harm note that people who have survived a medically
serious suicide attempt are more likely to have poorer outcomes in terms
of life expectancy (National Collaborating Centre for Mental Health, 2004).
There is evidence of an independent association between a person’s physical
ill health and their self-harm but it is not clear whether this is associated with
pain or personality factors (Goodwin et al, 2003).
4. Wider social concerns
Social context
Multiple factors
Although there is a high level of mental disorder among people who self-
harm or take their own lives, there are also many who do not have a
diagnosed mental illness, and for those who do, their actions are a result of
other causes.
This fact has an important bearing on the role and the limits of the role
and responsibilities of mental health professionals. It is not surprising that
for that reason 30% of the respondents to the College survey considered
that it was not primarily an issue for psychiatrists.
‘The main triggers for self-harm are usually social, particularly family,
issues, relationship break-up. Social workers should have more of a role
rather than mental health services … Life coaches, youth workers (e.g.
Connexions), would be better people to offer this service as they often
need housing/training/change of peer group.’
There is, as one respondent put it, a danger of ‘overmedicalising

the expressions of ordinary human distress’. The reasons people give for
precipitating their self-harming behaviour and the knowledge gleaned
from research for both self-harm and suicide include a wide range of
sociodemographic and personal factors. The Choose Life suicide prevention
strategy (Scottish Executive, 2002) lists them under the headings of risks and
pressures within society, within communities, for individuals and the quality
of the response from services. A diagram is reproduced in Appendix III.
Individual elements include personality traits, family experiences, life
events, exposure to trauma, cultural beliefs, social isolation and income.
Other factors such as education, housing and wider macro-socioeconomic
trends such as unemployment rates may also contribute directly, or by
influencing a person’s susceptibility to mental health problems. Socially
deprived people living in urban areas have been shown to have a higher risk
of self-harm (Corcoran et al, 2007; Royal College of Psychiatrists, 2008b).
As Mr Joe Ferns from the Samaritans told us (personal communication,
2009),
‘There are multiple factors and multiple different pathways that lead to
suicidal behaviours; and suicide is a multi-determined event, meaning
that it is generally not the consequence of a single issue but the
combination of several issues in a person’s life.’
Dr Roberts from DrugScope described the complex issues that may

underlie a person’s behaviour to the Working Group as follows:

‘Where someone is, for example, homeless, with a history of mental

health problems and, say, opiate dependent all these factors will be
relevant to the issues of self-harm and suicide … Self-harm and suicide
are not simply medical problems, amenable to therapeutic solutions,
they need to be understood in context. For example, loss of housing or
work could lead someone to relapse into problematic alcohol or drug
use, which in turn could be linked to self-harm or suicide’. (Dr Roberts,
personal communication, 2009)
Self-harm occurs in people of all ages but unsurprisingly rates of self-

harm are higher among those who are unemployed, single, live alone, are
in debt and have problems with alcohol (National Collaborating Centre for
Mental Health, 2004). Social isolation and breakdown in family and other
personal relationships are regularly cited as causing self-harming behaviour
(Haw & Hawton, 2008).
A Scottish study of those who repeatedly self-harm (Appleby et al,
2008) highlighted poor parenting, alcohol-related problems in childhood,
adult patterns of alcohol or drug use and violence together with the
community environment as some of the factors for self-harm and called for
a mixture of public policy and practice (including health service) targeted
‘upstream’, especially at causes of social exclusion.
Another very important issue is a history of past sexual abuse. The
impact of the experience of childhood abuse on adult self-harm is now well
established and its link with suicidal behaviour, particularly among women,
has been recorded (Bebbington et al, 2009). A Canadian study found that
where abuse was repeated, and where there was sexual abuse by a member
of the immediate family, there was a stronger association with suicide
attempts (Brezo et al, 2008).
Self-harm in adolescents is associated with many social problems
(O’Connor et al, 2009b), confusion over sexual orientation and sexuality
(Rehkopf & Buka, 2006), problems with boy-/girlfriends, and the occurrence
of physical or sexual abuse. Personal characteristics such as perfectionism,
pessimism, self-criticism and impulsivity also play a role (Fliege et al, 2009).
Whether there is a link between a person’s self-harming behaviour and what
is currently taking place among family members and friends is less clearly
established (Corcoran et al, 2007). Another study of adolescents aged 15–16
also cited isolation, problems with school and arguments with family or friends
(Samaritans & Centre for Suicide Research, University of Oxford, 2003).
Some precipitating and protective factors for suicide

People who are unemployed are two to three times more likely to die by
suicide than people in employment (Platt, 2003; Rehkopf & Buka, 2006;
O’Reilly et al, 2008), with unemployed men particularly at risk (Hawton et
al, 2001). In addition, unemployment can itself contribute to poorer mental
health, induce anxiety and depression, lower self-esteem and increase
feelings of hopelessness – all of which increase the likelihood that someone
will think that life is not worth living. People in debt and those who are
homeless are particularly vulnerable (Shelter, 2004).
The context of a person’s life and their character may protect them
from suicide and give them resilience to deal with adverse circumstances.
Problem-solving and social adjustment skills, high levels of reasons for living,
optimism, participation in sporting activity, positive family and other personal
relationships, and engaging with their community may modify the risks for
Wider social concerns
people who are also despairing of their life. The atmosphere, organisation
and practices of a person’s environment (McLean et al, 2008), such as in
schools, universities, workplaces, hospitals and prisons, may influence the
extent to which exposure to risk is translated into suicidal behaviours. The
role that a person’s culture may have in increasing self-harm or protecting
individuals against it has not been widely researched although factors such
as religion are clearly relevant. For example, Islam and Christianity both
strongly condemn suicide-making religious people, and their family, deeply
upset and potentially ashamed by a suicide attempt (or suicide) (World
Health Organization, 2000).
Different age groups

Self-harm does not just appear in adolescence and with young people.
Children as young as eight have been found to have harmed themselves.
Although adolescent girls are more likely than boys to harm themselves
and overall women are more prone to harm themselves than men (Hawton
& Harriss, 2008), the rate in young men aged 15–24 years is rising more
quickly than in any other group. There are also significant differences in
incidence and methods of self-harm between men and women. Older people
who harm themselves are more likely to do so in an attempt to end their
life (National Collaborating Centre for Mental Health, 2004). Following an
older person’s self-harm the risk of completed suicide is also higher in their
first year (60–100 times), which increases with age (Fox & Hawton, 2004;
Hawton et al, 2007a). The only age group in England and Wales who are not
showing a reduction in suicide rates are those over 85 years of age and the
numbers in this age group with depression are projected to increase by 80%
by 2026 (McCrone et al, 2008).
Studies in older people have not found a correlation between suicide
attempts and socioeconomic status, levels of education, or childhood sexual
or physical abuse (McLean et al, 2008). However, isolation and being divorced
or widowed has been a contributing factor (Hawton & Harriss, 2006). There is
some evidence that physical ill health is associated with self-harm (O’Connell
et al, 2004), particularly that chronic or terminal physical illness increases
the risk of suicide. Overall, among older people, in contrast to younger
people, the main factor associated with self-harm and completed suicide is
an underlying mental illness, most often depression (Dennis, 2009).
In this area, perhaps more than any other, there are strongly differing
views about whether an increased rate of suicide in old age is or is not
because of a legitimate wish that some people have to bring their lives to
an end because of illness and pain, isolation and loneliness, or a loss of
capacity and purpose, or is always properly assumed to be pathological. The
clear ethical dilemmas should not stop us from undertaking research to see
how far some of the self-harm among older people should be considered
voluntary acts as distinct from those undertaken as a result of depressive
disorders that represent pathological mental states and are indicative of
mental illness. What is certain is that at least a significant number are
suffering from illnesses that are treatable and therefore it is important to
focus on how best to assess and address their needs. There are multiple
factors and many different paths that lead to suicide whatever the age of
the person. Understanding why someone chose to die may not always be
straightforward or indeed easily fully investigated (Mann et al, 2005; Hawton
& Van Heeringen, 2009a).

Ethnicity
Studies in Britain have found that women of South-Asian ethnicity have a higher
than average rate of self-harm compared with White men and women (Bhugra
& Desai, 2002). Those under 35 years are at a higher risk than older women.
There are inconsistent findings for self-harm rates among teenage girls.
The reasons identified for this difference include isolation and family
pressure from husbands demanding a less Westernised form of behaviour;
interference from parents-in-law; arranged marriages or the rejection of
an arranged marriage; isolation even within the wider community; cultural
conflict, and problems at school, including racist bullying. South Asian women
who engage in self-harm have also been found to be less likely than their
White counterparts to have a psychiatric disorder (Husain et al, 2006).
Studies of other ethnic groups are characterised by different definitions,
making comparisons difficult (Bagley & Greer, 1972). There is some evidence
of an increasing risk for people of Caribbean origin aged less than 35 years.
In a Manchester study (2005–2007) (Dickson et al, 2009), 60 Black
women had higher rates of self-harm than any other group; rates in Black
women were 24% higher than in White women aged 16 years and over.
South Asian women also had slightly higher self-harm rates than White
women. These findings are in contrast to rates in males. White men had the
highest incidence of self-harm, followed by Black men and South Asian men.
People from other ethnic groups (including Chinese and mixed race) had
the lowest self-harm rates overall. Chinese men in particular had very low
rates of self-harm at 44 per 100 000 population. Rates in Chinese women,
however, were over three times as high, at 154 per 100 000. In Oxfordshire,
in the 16–35 age group, Black females were significantly more likely to self-
harm than their White counterparts (Hawton et al, 2007a). However, the
same report showed that in the 35–65 age group the trend was reversed
(Hawton et al, 2007a).
Groups of people at particular risk of self-harm

There are other groups who are specifically vulnerable because of life
experiences, personal or social circumstances or a combination of these
factors, underscoring the diverse kinds of suffering leading to self-harming
behaviour, and the complex relationship between mental illness and
self-harm. We do not claim to be comprehensive and do not cover those
professions that bring greater risk at particular times (e.g. farmers).
However, we highlight some disadvantaged groups: prisoners, asylum
seekers, veterans from the armed forces, people bereaved by suicide, people
of sexual minority groups and suicide bombers.
Prisoners
People in prison are unusually susceptible to self-harm and suicide. Male
prisoners are five times more likely than men in the general public to die by
suicide, while the rate among young offenders is 18 times higher (Fazel et
al, 2005). Self-harming behaviour is also widespread in prisons, the rates
for both genders being higher than in the general population (Her Majesty’s
Chief Inspector of Prisons for England and Wales, 2007; Cabinet Office et
al, 2009). Young people are overrepresented in these figures (Mental Health
Foundation, 2006.
The nature of the prison environment is likely to exacerbate a person’s
previous self-harming behaviour and their vulnerability to starting it. The
Joint Committee on Human Rights reached the conclusion that:
‘The evidence we have gathered suggests that prison actually leads to
an acute worsening of mental health problems. By sending people with
a history of attempted suicide and mental health problems to prison
for minor offences the state is placing them in an environment that is
proven to be dangerous to their health and well-being.’ (Great Britain
Parliament Joint Committee on Human Rights, 2004: p. 32)
The WHO’s Health in Prisons project listed negative factors in prisons

that are likely for the majority of prisoners and which are also associated
with self-harm (Gatherer et al, 2005).
Suicides are more likely to occur in the first few months of custody
(Prison Reform Trust, 2009). The risk can be reduced by sensitive treatment
by prison staff, and by the capacity of the prison to respond to the prisoner’s
concerns. A Prison Reform Trust report (Jacobson & Edgar, 2007) highlighted
the need for prisons to find ways of dealing with outside problems that
concern new prisoners the most. One prisoner told the Prison Reform
Trust:
‘All these things – like wife, mortgage, kid – they’re all hitting your head
at once. These sort of things need to be looked at: outside things, and
how you’re feeling inside. Or things like thinking I’m going to kill myself
come out of the blue ... If you get help, you don’t have to go through
these things.’ (Jacobson & Edgar, 2007)
Other environmental factors that have been linked to an increased

risk of suicide include uncertainty about legal status (Her Majesty’s Chief
Inspector of Prisons for England and Wales, 2009) and prison overcrowding
(Great Britain Parliament Joint Committee on Human Rights, 2004).
Women prisoners and self-harm

Women prisoners account for about half of all self-harm incidents in prison,
even though they comprise only 6% of the total prison population (Ministry
of Justice & National Offender Management Service, 2008). Women recently
released from custody are 36 times more likely than the general population
to die by suicide (Pratt et al, 2006). Women in prison are more prone to self-
harm repeatedly than men.
The higher risk of self-harm and suicide among women prisoners
suggests that women prisoners face particular risk factors. These are
highlighted in the Corston Report, an inquiry into the particular vulnerabilities
of women offenders (Corston, 2008). Women have significant unmet
needs that relate to their offending. These cover education, training and
employment, housing and income. Their offending is more directly related
to poverty and financial difficulties than male offenders. Prison is also said to
be harsher for women because prisons and the practices within them have
been designed for men.
Women prisoners are more likely than men to be primary carers of
young children, which affects their experience of prison. Because there are
fewer women’s prisons, women are more likely to be located further from

their home than male prisoners to the detriment of maintaining family ties,
receiving visits and resettlement into the community. These factors, which
increase women’s vulnerability, are likely to be associated with high rates of
self-harm both before and during prison life.
‘I entered prison as a person of sound mental health. During my
incarceration, I experienced many mental health problems such as
medical dependency, self-harm and suicidal thoughts and severe weight
loss, due to the unbearable pain of separation from my daughter and
being in prison.’ (Rickford, 2005)
Asylum seekers
Asylum seekers have often experienced traumatic events in their home
country; indeed a well-founded fear of persecution on specific grounds is the
sole basis of a claim for refugee status. Studies have consistently revealed
high levels of mental health problems, especially anxiety, depression and
PTSD in detained asylum seekers. They have higher rates of self-harm
and suicide compared with the UK prison population (Cohen, 2008). The
length of time in detention and the nature of the process itself particularly
intensify their distress (Hawton & Harriss 2009b). The practice of detention is
controversial and the conflicting priorities of clinicians and government in this
regard complicate any attempt at solutions that do not involve detention.
Veterans
A study of 233 803 personnel leaving the UK military forces between 1996
and 2005 reported that young men aged 24 and younger have been found to
be at a particular, and persistent, risk of suicide – two to three times higher
than for the same age groups in the general population and those still serving
in the forces (Kapur et al, 2009). The risk was greater among males, those
with a short service and those of lower rank. The next phase of the Suicide
Prevention Strategy for England will develop strategies targeted at this group
of people. They include practical and psychological preparation for discharge
and encouraging people to seek help after leaving the services. The sad
truth is that as a country we pay less attention to the post-discharge needs
of our veterans than, for example, the USA, which has substantial veteran
health and support facilities. It is clear that many veterans suffer adverse
psychological sequelae of their service careers. For many ex-servicemen and
women, the full tragic outcome only becomes overwhelming many years
after their return to civilian life, and because there has been little follow-up
of ex-service personnel the evidence has only recently begun emerging from
research work.
Lesbian, gay and bisexual people

Lesbian, gay and bisexual people are subject to prejudice, discrimination
and social exclusion (including within families). They may experience anti-
homosexual hostility and violence, and they may internalise a sense of
shame about their sexuality. Misuse of alcohol and drugs may also increase
their vulnerabilities to mental disorder and self-harm. A systematic review
of mental disorder suicide and self-harm among lesbian, gay and bisexual
people found a higher risk of self-harm, mental disorder and substance

misuse than in heterosexual people (King et al, 2008). In general, the hidden
nature of sexual orientation makes evidence on vulnerability to suicide hard
to obtain and thus it was not clear whether or not this resulted also in higher
rates of suicide. Nevertheless, the close association between rates of self-
harm and subsequent suicide makes it likely that this group are at higher
risk for suicide. The authors concluded that their findings were at least partly
attributable to the social and psychological circumstances mentioned above.
Their findings need to be fed into planning for public health measures and
for health services.
Suicide bombers
It is impossible to consider the issue of self-harm and suicide in the present
international security climate without being aware of so-called ‘suicide
bombers’. Research work has been done in various parts of the world,
including in South Asia and Israel, but the Suicide Terrorism Database
in Australia is probably the most comprehensive in the world, holding
information on suicide bombings in six countries accounting for 90% of all
suicide attacks between 1981 and 2006. As with others, the evidence from
this source suggests that:
‘though religion can play a vital role in recruiting and motivating
potential future suicide bombers, the driving force is not religion but a
cocktail of motivations including politics, humiliation, revenge, retaliation
and altruism.’ (Hassan, 2009)
The configuration of these motivations relates to the particular

circumstances of the violent political conflict in which there has been the
appearance of suicide attacks in different countries. Suicide bombers are not
likely to display either personality disorders or mental illness (Hassan, 2010).
As Professor Riaz Hassan explains,
‘The causes of suicide bombings lie not in individual psychopathology
but in broader social conditions. Understanding and knowledge of
these conditions is vital for developing appropriate public policies and
responses to protect the public.’ (Hassan, 2010)
These findings are congruent with the work of most serious scholars
in the field of terrorism generally and suicide terrorism in particular. The
implication seems to be that there is little hope that such people can be
identified in advance, especially in the UK. In the Middle East and Chechnya,
some individuals have been the bereaved partners of militants killed in other
operations, but such personal psychological identification seems to be the
exception rather than the rule, as is the case with most terrorists.
Whatever the popular sentiment, scientific research points to terrorism
(including terrorism in which the militants sacrifice themselves in the process
of carrying out the incident) being more a result of group than of individual
psychology (Alderdice, 2007).
Identifying people who might be vulnerable to recruitment into terrorist
activity generally is currently being addressed with some energy through the
PREVENT component of the UK government’s domestic counter-terrorism
strategy (CONTEST). The most recent version Pursue Prevent Protect Prepare
(HM Government, 2010) is available on the Home Office website. How
successful it will be remains to be seen.

Carers, friends and family members

Carers and family members of people who self-harm are not themselves
a minority group but their closeness to the person who self-harms clearly
makes them vulnerable to psychological distress. This is likely to be most
acute for parents of young people who self-harm and for those who have
been bereaved by suicide (Department of Health, 2008). Mothers and
siblings in particular have been shown to suffer episodes of depression after
a child’s suicide.
Carers may feel isolated, stigmatised and burdened with the anxiety
of caring for a family member or friend. They may feel hostile (Griesbach et
al, 2008). Parents of young people may feel helpless and excluded as their
children confide in their peers rather than themselves. (Young people have
been found to be more likely to disclose their self-harming behaviour to their
friends than to their families (Csipke & Horne, 2008).) Feelings, especially
shame or guilt, may be exacerbated by the cultural environment or their
religion.
‘Supporting a friend or relative who self-harms can be distressing,
frustrating, confusing and draining as well as rewarding and an
opportunity to build a closer relationship. Given these emotions carers
should be, where possible, included as part of the team and respected
for their knowledge and expertise. Carers can have a profound impact
on good recovery outcomes.’ (V. Kamerling, personal communication,
2010)
The process of grieving can take longer and involve greater negative
emotions when a loved one has been lost by suicide rather than with a
natural or accidental death. It can also be accompanied by recurring images,
as well as feelings of guilt or abandonment (Department of Health, 2008).
5. Interventions
A Cochrane systematic review of interventions for self-harm will be published

late in 2010, and the NICE Guideline Development Group will publish its draft
in 2011. These guidelines will provide more up-to-date and comprehensive
accounts that we can here. Although an empathic approach is essential
in dealing with people who self-harm, it is not clear that any one form of
treatment is particularly effective, and in some cases, the most pressing
need is to address the underlying social issues or addiction problems.
Service user studies

Most studies on interventions focus on clinical outcomes that use the
reduction of self-harming behaviour as the key measure. A small number of
studies of service users’ views have identified the usefulness of counselling
over medication, but the structured research evidence base is weak (Smith
& Clarke, 2003).
Evidence from young people to a recent inquiry reported the value
of self-support groups and is supported by research into the general
effectiveness of these groups (Adamsen & Rasmussen, 2001).
Engaging service users in assessing appropriate interventions has been
relatively neglected. One small study (Hume & Platt, 2007) involved service
users with varying themes and backgrounds to their self-harm (e.g. psychiatric
illness, alcohol dependency, traumatic life events, chronic life problems).
These themes affected their experiences of and attitudes to interventions for
self-harm. The study found that personal circumstances and life history are
major influences on the choice of interventions for self-harm. Nevertheless
there was a clear preference for specialist community-based interventions,
which focus on the provision of immediate aftercare and acknowledge that the
management of self-harm may not necessarily involve its prevention.
Case study 5.1

The Crisis Recovery Unit at the Bethlem Hospital in London is a national specialist
residential unit for people of 17 years and above who persistently harm themselves in
serious ways. The philosophy of the Unit is that individual young people should retain
responsibility for their behaviour, and that – in the short term – self-harm can sometimes
be tolerated, although not promoted. This is termed ‘therapeutic risk’. The approach is
based on the view – supported by practice experience – that if staff remove all potentially
damaging items and take full responsibility for the young person’s immediate safety, the
young person does not make the choice themselves. In the long term, by the time they
leave the Unit, they need to have learned their own strategies for coping with the urge
to harm themselves. The aim is to help young people start to explore alternative coping
strategies, and strategies for dealing with the urge to harm themselves (Mental Health
Foundation, 2006).

Case study 5.2

Selby and York Primary Care Trust has recently developed a self-harm handbook to
assist in the engagement, formulation and early stages of intervention with working-age
adults (Pengelly & Ford, 2005). Using a cognitive–behavioural model, it aims to address
causes and maintenance cycles for repeated self-harm. The handbook is designed to be
worked through with the professional(s) involved in the care of someone who has harmed
themselves. It is one part of a continuing and comprehensive care plan and should only
be used when a service user has given informed consent, is aware of the purpose of the
handbook approach, is aware of alternative treatment options, and is not experiencing
symptoms of acute mental illness.
Clinical interventions
The NICE guidelines (National Collaborating Centre for Mental Health, 2004)
examine psychosocial, pharmacological and social service interventions for
self-harm, in each case finding little evidence of what works and for whom,
and very little evidence of what does not work. Since then, a Scottish
systematic review has been published (Leitner et al, 2008), and a new
Cochrane review on psychosocial and pharmacological treatments for self-
harm is due to be published in 2010. Systematic reviews of interventions
have evaluated the effectiveness of various types of interventions after
incidents of self-harm (Hawton et al, 1998; NHS Centre for Reviews and
Dissemination, 1998; Fox & Hawton, 2004; Van der Sande et al, 2007). The
evidence is largely based on studies of people attending hospital accident
and emergency services. Most of the literature focuses on self-poisoning,
while there is remarkably little on effective therapeutic interventions for
people who intentionally cut themselves. Indeed, Fox & Hawton (2004)
found no UK-based controlled intervention studies of people who engaged
solely in cutting themselves.
In addition, the majority concentrated on reductions in incidents of
self-harm rather than mood or quality of life, or what the people involved
themselves wanted to achieve. It is difficult therefore to reach conclusions
about effective interventions from these studies. Given the size of the
population that is at risk from self-harm, and the relation of repeated self-
harm to suicide, this is a matter of great concern.
One review of 18 randomised controlled trials noted that some trials
of psychosocial treatments have demonstrated statistically significant
reductions in the likelihood of repetition of non-fatal self-harm (Crawford et
al, 2007). However, as the review cautions, ‘such findings do not necessarily
mean that these treatments would reduce the likelihood of subsequent
suicide’. A Cochrane review (Hawton et al, 1999) concluded that there were
promising results for problem-solving therapy, provision of a card to allow
patients to make emergency contact with services, depot flupenthixol for
recurrent self-harm, and long-term psychological therapy for female patients
with borderline personality disorder and recurrent self-harm. They also
reported that assertive outreach can help to keep patients in treatment.
What kinds of therapeutic interventions?

There is a good deal of evidence to suggest that CBT is effective in improving
future thinking, decreasing levels of depression and reducing incidents of
Interventions
self-harm (Slee et al, 2008). Evidence also suggests that CBT is effective for
patients with recurrent and chronic self-harm.
Problem-solving therapy is a related brief treatment aimed at
assisting a person to develop the psychological resources to resolve their
own problems. It teaches basic problem-solving skills, and has been found
effective in reducing depressed mood, hopelessness and poor problem-
solving in other settings (Hawton et al, 2009). In self-harm studies it has
led to improvements in mood and social adjustment (House et al, 1992).
It is unclear from the existing evidence how widely it could be applied, and
further work is needed to build up an evidence base. Research has been done
into different types of problem-solving ability (McAuliffe et al, 2006) and its
relation to repetition of self-harm, with conclusions for future practice.
‘Problem-solving therapy is a pragmatic approach which may be
suitable for a sizeable proportion of deliberate self-harm patients. It
has the advantage of being relatively easily taught, usable by a range
of clinicians, brief and comparatively cheap. It has been demonstrated
to be of value in the treatment of patients with emotional problems in
general practice.’ (Townsend et al, 2001)
As with other interventions for young people, family therapy may

be useful in some circumstances; however, this has yet to be rigorously
assessed (Harrington et al, 2000).
Although dialectic behaviour therapy has been gaining currency in
some places, evidence of its clinical effectiveness is lacking. The Scottish
systematic review reports that there is some indication of effectiveness with
people with personality disorder (Leitner et al, 2008).
Evidence from one study (and referred to in the Cochrane review as
noted earlier) suggested that crisis cards may be effective for people who
have harmed themselves for the first time (Morgan et al, 1993). However,
a later and much larger randomised controlled trial found to the contrary,
so although there may be a ‘self-evident’ benefit of people being discharged
from hospital receiving cards to remind them and assist follow-up, there is
at present no clear evidence of a beneficial impact (Evans et al, 2005).
The Scottish systematic review (Leitner et al, 2008) addressed suicide,
suicidality and self-harm. It found limited evidence of the effectiveness of
available interventions to reduce completed suicide but reported that the
most promising interventions for attempted suicide included the provision
of informal social support (e.g. the Samaritans and the restriction of access
to means) (Gunnell et al, 2000; Morgan et al, 2007; Hawton et al, 2009). In
relation to self-harm, there was also some ‘less-convincing’ support for the
efficacy of ongoing contact. It found some limited evidence in the context of
hospital presentations that referral for specialist support may be of value.
Where self-harm is attributable to a psychiatric illness, pharmacological
intervention may be markedly helpful in managing the underlying problem
and therefore the danger of repeated or more dangerous self-harm. However,
the evidence for the usefulness of pharmacological interventions specifically to
address self-harming behaviour beyond definite psychiatric illness is limited.
‘Clinicians wanting to use pharmaceutical therapies would currently be
justified in using lithium to prevent attempted suicide in people with
bipolar disorder (but should exercise caution given reports of adverse
outcomes) and either fluvoxamine or sertraline to prevent suicidal
ideation in people with depression, but beyond these rather limited
options the available evidence becomes decidedly equivocal.’ (Leitner
et al, 2008)

Individual studies have shown benefits of clozapine for patients with

schizophrenia (Alphs et al, 2004; Ernst & Goldberg, 2004).
Harm minimisation
Harm minimisation is a strategy, recommended by NICE (National
Collaborating Centre for Mental Health, 2004), only to be used in specialist
and dedicated services that allow people to harm themselves in a controlled
environment and with sterile instruments in order to ensure that any harm
done is as clean and well managed as possible. It could be unhelpful in
settings such as in-patient psychiatric wards, where the contagious spread
of self-harm may be an issue.
The theory underlying this approach is that self-harm is a coping
mechanism, and if it is immediately halted and no replacement offered a
more damaging activity may replace it. Ms Sue Waterhouse gave evidence
to the Working Group to the effect that in her experience, harm-minimisation
techniques, together with psychological support and talking therapies, can be
very effective in reducing self-harm activity. The majority of views expressed
in the College Members’ survey were also positive (www.rcpsych.ac.uk/
risktoself).
The view, similar to that expressed directly by some service users,
is that the forcible restriction of the ability to harm can have negative
consequences and can forestall the efficacy of a talking therapy. Although
allowing someone to harm themselves does contain an element of risk, it is
said that this risk is outweighed by the potential benefit.
There is considerable controversy surrounding the use of harm
minimisation and concern that the guidance can be taken out of context
– guidance on harm minimisation is said to be not readily available
and therefore misunderstood (Pengelly et al, 2008). The use of harm
minimisation in prisons is currently under review. Given the controversy
around this treatment, guidance needs to be much clearer that harm
minimisation must at all times be in a contained environment, be supported
by talking therapy and that it is unacceptable and bordering on malpractice
if it is not. To reinforce this point, it was suggested that a less provocative
name should be employed.
Specific local interventions

In particular localities there may be a place that has become a regular site
for people who wish to harm themselves or take their lives – a bridge over
a river or a bridge that is particularly high or dramatic. In response to a
high incidence of deaths or harm at such places professionals and voluntary
organisations have sometimes set up local initiatives to enable them to
intervene and provide help (Case study 5.3).
Case study 5.3

At the Robert Gordon University in Aberdeen, Professor David Alexander has worked closely
with local police to provide early professional, psychological intervention and negotiation in
hundreds of ‘critical incidents’ where threat of suicide or self-harm had been drawn to police
attention, and in Londonderry (Northern Ireland) local taxi drivers were provided with basic
training and life-saving equipment to respond to sightings of people who were threatening
to or had actually jumped into the river Foyle. In both examples these interventions have
been demonstrated to save lives (D. Alexander, personal communication, 2010).
Interventions
It is important that psychiatrists and other mental health professionals

do not restrict their thinking about prevention and intervention to those
things that can be done in the clinic, but engage with and in the local
community in addressing self-harm and suicide.

Part II
The public health agenda
6. The cost of self-harm
Aside from the physical and mental impact on the person who harms
themselves and the impact on the people who work with them, there are
economic costs incurred by the act of self-harming. The economic cost of
self-harm on a national level has not been calculated, although the direct
cost to the National Health Service (NHS) has been estimated at £5.1 million
per year from self-poisoning with tricyclic antidepressants alone (National
Collaborating Centre for Mental Health, 2004: pp. 25–26). The indirect
economic costs of self-harming behaviour to an individual and their family
are unknown but are likely to be substantial, especially in terms of days lost
from work and other activities, including family responsibility.
The lack of systematic collection of data around self-harm impedes
research in this area. However, a recent study (Sinclair et al, 2010) found
that patients who engage in self-harm have significantly higher overall
health service costs in the 6-month period around an episode. There was a
cumulative effect on resource costs with increasing episodes of self-harm,
particularly for patients with five or more episodes. The highest costs were
attributable to in-patient psychiatric care.
The costs of suicide to society include direct economic costs, such as
services used (e.g. coroners, police), indirect economic costs such as the
value of potential work and earnings lost, and intangible costs, including
the human costs of suffering, grief and loss, and the associated morbidity,
as well as non-market outputs such as voluntary work, and caring for the
family. Although there is debate about how to put a monetary value on
intangible costs, the government in Northern Ireland in 2004 estimated that
the total cost per suicide, including economic and intangible costs, was £1.4
million (Department of Health & Social Services and Public Safety, 2006).
Whether or not this can be replicated elsewhere, the cost to society makes
this a significant public policy issue.
Given the widespread incidence of self-harm within society, the fact
it affects all age groups, that its causes are social and economic as well as
health based and that there are high-risk groups who are least likely to have
access to good healthcare, it is clear that the issues should be addressed by
government health policy and public health strategies (Platt et al, 2007).
General mental health policy

In 2009, the Scottish government launched Towards a Mentally Flourishing
Scotland: Policy and Action Plan 2009–2011. This document included the
reduction of the incidence of suicide, self-harm and common mental health
problems as a strategic priority.

In 2009, the UK government introduced New Horizons as its new

mental health policy for England and Wales (Department of Health 2009a).
It was based on the major themes in current government health policies
– recovery, personalisation and person-centred care. Recovery involves
engagement with the patient/service user as an equal partner in the process
of treatment and care, their empowerment, a focus on their strengths
and assets, and assiduous attempts at fostering optimism and hope for
the future. In principle these approaches might be expected to decrease
the occurrence or severity of self-harming behaviour and the likelihood
of completed suicide, and individual service users and professionals have
reported better outcomes from such approaches. New Horizons promotes
the development of measures for services and tools to ensure that care is
planned around user-defined goals and quality of life outcomes. It promotes
the involvement of service users in the planning and delivery of care.
7. Strategies for the prevention
of self-harm and suicide
Suicide prevention strategies have now been established in Scotland, Wales,

Northern Ireland, Ireland and England. They cover broadly the same areas,
although with somewhat different approaches and different strengths. The
suicide prevention strategy for England, for example, deals less with wider
prevention measures such as public information and involvement of front-line
staff beyond mental health.
The National Suicide Prevention Strategy for England (Department of
Health, 2002a) included targets for reducing the death rate from suicide
and undetermined injury by at least 20% by 2010. This target was reflected
in key policy documents, including public service agreement targets, NHS
operating frameworks, health and social care standards and, until recently,
the National Service Framework for Mental Health (Department of Health,
1999).
The government’s new programme of action for mental health, New
Horizons, has committed to updating England’s suicide prevention strategy,
taking into account ‘changing demography, the current economic climate
and special at-risk groups, for example young men leaving the forces, older
men and rural communities’ (Department of Health, 2009a). However, the
targets have been abandoned.
Scotland’s Choose Life suicide prevention strategy (Scottish Executive,
2002) is a 10-year plan aimed at reducing suicides in Scotland by 20%
by 2013. This was reinforced in Better Health, Better Care (Scottish
Government, 2007). The Choose Life strategy recognised that effective
strategies to reduce suicide need to be mindful of the overlap between
suicidal behaviour and self-harm. However, the strategy included only
those aspects of self-harm that may be considered as an indication of
risk of suicide. In 2006, the Scottish Executive recommended that more
consideration should be given to self-harm, including guidance about how
incidence of self-harm is to be measured and what target for its reduction is
to be set (Scottish Executive, 2002).
Towards a Mentally Flourishing Scotland included the reduction of the
prevalence of suicide, self-harm and common mental health problems as one
of its six priorities (Scottish Government, 2009). To meet these priorities,
the Scottish government committed to working with partners to improve the
knowledge and understanding of self-harm by:
agreeing a definition of self-harm and developing a non-stigmatising
language and description of self–harm;
increasing awareness of self-harm and its determinants;

mapping and assessing existing training provision and projects across

Scotland;
increasing understanding of effective methods of prevention and
offering guidance to those delivering both general and specific
services;
developing local and national information.
In 2006, Northern Ireland launched a 5-year strategy, Protect Life:
A Shared Vision, Northern Ireland Suicide Prevention Strategy and Action
Plan 2006–2011 (Department of Health & Social Services and Public Safety,
2006). The overarching aim is to reduce the suicide rate in Northern Ireland,
incorporating targets of a 10% reduction in overall suicide rate by 2008,
and by a further 5% by 2011. The strategy contains 62 cross-departmental
objectives with specific, targeted actions incorporated within 13 objectives.
In 2008, Wales launched a 5-year strategy called Talk to Me: A National
Action Plan to Reduce Suicide and Self-harm in Wales 2008–2013 (Welsh
Assembly Government, 2008). It has seven strategic objectives, including a
specific objective to manage the consequences of suicide and self-harm. Each
objective is supported by a set of actions with a timetable for implementation
over the 5-year period.
According to the National Suicide Prevention Strategy for England
Annual Report on Progress (National Mental Health Development Unit, 2009),
the suicide rate for the year 2007 was the lowest recorded. There was a rise
in the past year; nevertheless, the strategy has achieved a result close to
the target set for the decade, demonstrating some success for this strategy
(National Mental Health Development Unit, 2009). In Scotland there was a
10% fall in suicide rates between 2000 and 2002 and between 2006 and
2008, although rates in men have increased marginally in the latest 3-year
period.
Despite these welcome downward trends, suicide remains a significant
cause of death and its prevention a major public health issue. The sudden
and traumatic nature of a death by suicide can have a devastating effect on
the close relatives and friends of the individual and the impact may even be
felt throughout a local community.
In England and Scotland, a target for suicide prevention has been
discontinued. Targets have had drawbacks and perverse incentives in various
aspects of healthcare; however, their entrenchment in various public sector
agreements and operating frameworks did require regional and local bodies
to take action. Given that structures and mechanisms for implementation
are vital to the successful outcome of national strategies, there will need to
be adequate capacity and monitoring at regional and local levels of outcome,
and effective mechanisms for ‘joined-up working’ across government
departments and agencies as well as between the government and the third
sector. There is some anxiety about implementation with changes in the
structures in the UK as well as the effects on public finances in the aftermath
of the economic crisis – these anxieties have been expressed particularly in
regard to the implementation of New Horizons in England.
In England and Scotland, the coordination of suicide prevention by
specific post-holders has been replaced by responsibility within the NHS,
usually given to someone as part of a larger role. One fear is that the
visibility of suicide prevention and the ability to coordinate cross-agency
and sector working for suicide prevention could be undermined. The newly
launched suicide prevention strategy for Wales, by contrast, has placed the
Strategies for the prevention of self-harm and suicide
responsibility for implementing suicide prevention in local service boards,

which bring together leaders of local public and third-sector organisations
that may be well placed to enable cross-agency and sector delivery of suicide
prevention, as opposed to the health services.
A large number of the people who end their lives by suicide are not in
contact with mental health services. For example, in 2009 ‘around 75% of
the 4000 people who take their own life each year in England were not in
contact with mental health services’ (Department of Health, 2009a), and this
proportion is unchanged since 2002 (Appleby et al, 2001). Similarly, with
self-harm, the majority are not in touch with services (Meltzer et al, 2002).
For this reason alone, national and local policies and strategies need
to proactively target and include the statutory and voluntary services.
These services notably may include primary care and acute care, general
healthcare (including palliative and terminal care), the education sector,
prisons and the criminal justice system, youth services, substance misuse
services, housing associations, Black and minority ethnic communities, and
third-sector organisations.
There is now almost a decade of potential learning from the
implementation of different practices of suicide prevention across the UK
but no clear mechanism for comparison of outcomes and coherent learning
across the nations. There should be more coordinated sharing of knowledge
across the nations. Indeed, New Horizons acknowledges that the UK-wide
framework for suicide prevention needs to be strengthened.
Recommendations
•• Suicide prevention should remain a priority of public health policy in all countries in the UK. There
should be structures at national, regional and local level and mechanisms for the flow of information,
evaluation and best practice to ensure effective implementation. A partnership approach to
implementation should be adopted wherever feasible.
•• The needs of those at particular risk (including asylum seekers, minority ethnic groups, people in
institutional care or custody such as prisoners, people of sexual minorities, veterans, and those
bereaved by suicide) should be actively addressed as part of this strategy.
•• A UK-wide forum should be established to bring together agencies from the four nations who are
involved in suicide prevention policy, research and practice.

8. A public health approach
specifically to address self-harm
The New Horizons policy (Department of Health, 2009a) and Towards a

Mentally Flourishing Scotland (Scottish Government, 2009) both put public
mental health firmly on the public health agenda, and self-harm should be
tackled explicitly in any general public health strategy to improve mental
resilience.
Self-harm is not necessarily an attempt at suicide or the prelude to a
later attempt, but given the rise in self-harm and the rising impact of alcohol
on rates of self-harm, it should feature strongly and in its own right either as
major part of a suicide prevention strategy, as it does in Wales and Scotland,
or as a separate public health strategy. The context of self-harm includes
significant damaging social problems.
‘I do not believe we should be pretending that we can, or be trying
to, provide a panacea for this significant problem. Pressure should be
brought by us for the government to focus on strategies seeking to
promote: unity in families; better services for the unemployed; greater
availability, and higher quality, of social housing; and higher-quality
secondary education with sport for all. Perhaps (optimistically, I concede)
if we take responsibility for those people for whom mental disorder is
a significant contributor, then others (housing, education, Department
for Work and Pensions, etc.) will take some responsibility for the part
they have to play!’ (Respondent to Working Group College Members’
Survey)
The range of family, social and economic factors that underlie self-
harm and the fact that it appears in all age groups, further underscores
its relevance to many different government departments apart from the
Department of Health. The need for intervention in schools has been
powerfully made in research (Hawton et al, 2006) and, as we have identified
already, there are high-risk populations such as prisoners, veterans, those
in care and asylum seekers, as well as issues of gender, sexuality and race
to consider. Addressing the problem is therefore a matter of relevance for
Department for Education, Department for Business, Innovation and Skills,
Ministry of Justice, Home Office (immigration), local government, families
and communities, and Ministry of Defence.
In light of this, there ought to be a cross-departmental strategy on
self-harm led by the Department of Health. Truth Hurts (Mental Health
Foundation, 2006) called for such a strategy in relation to children and young
people, but we consider that there must be one for adults of all ages. The
ageing population makes self-harm in that group particularly ripe for serious
consideration.
A public health approach specifically to address self-harm
A cross-departmental approach – drugs and alcohol

We have in Part I discussed the evidence of the relationship between
drug and alcohol misuse and self-harming behaviour or suicide. For this
reason, strategies to combat these addictions are central to reducing self-
harm. The Working Group supports the College policy positions on these
issues, including the call for minimum pricing of alcohol (Royal College of
Psychiatrists, 2009a). The risks of self-harm among people with alcohol
and/or drug problems – and the particular high risks for those with ‘dual
diagnosis’ – should also be key issues within a strategy.
DrugScope reported to the Working Group that in their view self-harm
and suicide remain marginal issues in drug and alcohol strategies. The two
most recent government directives on drugs and alcohol make no reference
to self-harm or suicide (Department of Health, 2007; HM Government,
2008). The National Treatment Agency’s major report on risk also made no
mention of self-harm and suicide (National Treatment Agency for Substance
Misuse, 2008). This reflects treatment on the ground, and is indicative of the
policy split between alcohol/drug misuse and mental health.
The issues of self-harm and suicide are also marginal in the
development of policy on dual diagnosis. The English Department of Health’s
Dual Diagnosis Good Practice guidance (Department of Health, 2002b)
recognises self-harm and suicide as key issues for services working with
people with severe mental health problems and problematic substance
misuse, but other policy documents (Care Services Improvement Partnership,
2007) pay little attention to it.
A significant number of people in the drug misuse treatment field lack
a background, experience or even training in mental health issues. This is
made more difficult by the high rate of staff turnover. The moves to place
drug and alcohol services in the voluntary sector places at risk the link with
the expertise of psychiatrists and other mental health professionals. It could
well be lost. There is already a lack of research and monitoring in this field.
‘We were able to find little information about how mental health or drug
services address the links between substance misuse (or use) and self-
harm or suicide (for example, good practice in assessment and treatment
planning). We need more research on practice, identification of good
practice and investment in appropriate resources, including training and
guidance. We would welcome work from the National Treatment Agency
in this area.’ (DrugScope, personal communication, 2009)
Recommendation
•• Those who deal with people who are suicidal or have been or wish to harm themselves should have
some level of training to assist them in understanding about the differences between mental illness
and reactions of distress and in knowing how to access expert psychological and psychiatric services.
Particular issues that need to be addressed
Information and public education

As recently reported (Harrison, 2010), people who self-harm do not always
understand what is happening to them or why they do it. Furthermore,

because of the stigma of self-harm, they may feel they are on their own.
Although excellent self-harm material is available in booklets and on the
internet, they may not be readily accessible or on well-known sites.
‘Information on how common self-injury is would be helpful. I used to
feel abnormal and weird as I thought I was the only person to do this.
Information could have helped reduce the shame and isolation this
caused me.’
Carers, friends and family members may play a vital role with their
loved one’s care. They are also likely to be worried and distressed by
behaviour they find hard to understand and need to be provided with
information they can feel confident is helpful and authoritative. There is a
need for public information to be readily available for carers in appropriate
and accessible formats.
‘There are some websites, but not trusted sites, or don’t seem very
professional. You need more official or trusted websites with more
information, e.g. like the NSHN. Apart from that, the NHS has very little,
except the small basic facts on the website. You need more supportive,
interactive or online counsellors to whom people can feel they can go
to. Maybe a discreet Facebook group would also help, to connect to
others who are in the same situation. Again there is very little public
information in leaflets, magazines or newspapers, so you feel you are
alone. You need more than just facts. You need case studies and stories,
human connection, understanding and support to go with the basic facts
of self-harm.’ (Naheen Ali, Service Users’ Recovery Forum)
A coherent public health strategy must not only make good material
available but also include addressing the problems of websites that glamorise
the problem of self-harm or show images of cuts and scars.
Recommendation
•• The Royal College of Psychiatrists should collaborate with other mental health organisations and
professional bodies to ensure that helpful and user-friendly information is available for diverse
audiences and purposes.
The role of the internet and the media

The role of the internet has generated much concern, particularly for its
effect on young people. There has been an upsurge in websites encouraging
self-harm and even promoting suicide, including discussion of methods of
suicide. Although some websites are helpful, some of the virtual relationships
developed through Facebook and chat rooms far from adult scrutiny or
advice can be unhelpful or positively dangerous. Intrinsic factors such as
isolation and disaffection may encourage imitation of risk-laden behaviour.
Relationships of this nature, sharing a unique private experience, can be
intensive and intimate and result in an increase in dangerous behaviour as
a result of exposure.
The number of young people admitted to hospital after cutting
themselves deliberately is up by more than 50% in 5 years according to new
figures (BBC Radio 1 Newsbeat, 2010). One in five schoolchildren with a
history of self-harming questioned by researchers said they first learnt about
A public health approach specifically to address self-harm
it after seeing or reading something online, second only to hearing about it

from friends.
‘I think the internet played a major role; I think it started off my self-
harm. I was already thinking about it so went to the web to find out
more. I just typed ‘self-harm’ and there were hundreds of videos. Some
are good but others can be very damaging. If I see a picture [of cuts], it
can encourage me to do it. Sometimes it’s a competitive thing.’ (Danielle
17, Belfast)
YouTube is quoted as agreeing that it will take down graphic material

but only if those videos deliberately tell or encourage other young people to
self-harm.
The Royal College of Psychiatrists has said that it is now ‘seriously
concerned’ about the growing number of websites that glamorise self-harm
or show gory images of cuts and scars. They are calling for website owners
and moderators to remove material that might promote or trigger self-harm
and to link directly to sites that offer professional help and support.
Australia has legislated against use of the internet to promote the idea
of suicide or provide advice about methods. However, some researchers in
Britain suggest that it may be
‘more fruitful for service providers to pursue website optimisation strat
egies to maximise the likelihood that suicidal people access helpful rather
than potentially harmful sites in times of crisis.’ (Biddle et al, 2008)
The role of the media in suicide has been the subject of much
debate and consideration by the government and third sector. The current
guidelines produced by the Samaritans (2008) aimed at those reporting
suicides call for caution and sensitivity in order to avoid copycat behaviour
as studies suggest that ‘media portrayal can influence suicidal behaviour’.
The guidelines advise, for example to avoid using ‘explicit details of suicide’
and labelling places as suicide hotspots and encourage the media to
promote an understanding of the complexity of suicide. The UK Editors’s
Codebook introduced a new rule for editors in 2006 that when reporting
suicide, care should be taken to avoid excessive detail of the method used.
The revised Codebook has expanded its section on reporting on suicide
with new guidance in the aftermath of the series of deaths of young people
in and around Bridgend, South Wales, and complaints against newspapers
about ‘excessive detail’ (Beales, 2009).
Recommendation
•• A public health strategy on self-harm should address the issue of monitoring of harmful websites.
Cross-sector training
All relevant studies of service user experiences demonstrate that the
essential qualities of empathy, understanding and skills are not always
readily available among the staff in various agencies (see pp. 68–70). They
cite the lack of understanding of the nature and causes of self-harm and
underline the need for effective training on self-harm for all relevant front-
line staff. Staff in drug and alcohol services and prison staff were singled
out for particular mention in evidence to the Working Group. Prison staff

have particular challenges in balancing their custodial and their welfare roles
(Short et al, 2009).
In Scotland, Wales and in some regions of England, awareness-raising
programmes are in place as part of suicide prevention strategies together
with training for front-line staff in a range of services, including teachers,
police and social workers. The ASIST (Applied Suicide Intervention Skills
Training), STORM (Skills-based Training On Risk Management) and similar
short-training schemes (Box 8.1) have been evaluated (Appleby et al, 2000;
Gask et al, 2006; Griesbach et al, 2008; Hayes et al, 2008; Harrison, 2010)
and show high levels of satisfaction from attendees.
Box 8.1 Awareness-raising programmes
•• ASIST (Applied Suicide Intervention Skills Training) is intended as ‘suicide first-aid’ training.
ASIST aims to enable helpers (anyone in a position of trust) to become more willing, ready
and able to recognise and intervene effectively to help individuals at risk of suicide. ASIST is
said to be by far the most widely used suicide intervention skills training in the world.
•• STORM is Skills-based Training On Risk Management for suicide prevention. The training is
intended for front-line workers in health, social and criminal justice services. It focuses on
developing through rehearsal the skills needed to assess and manage a person at risk of suicide.
The STORM package is designed to be flexible and adaptable to the needs of a service.
•• Other training resources and approaches are available. For example, Connecting People in Wales
is designed to raise awareness and act as a ‘feed’ into more in-depth training for front-line
services. The short introductory session aims to build relationships with the family and to use
the term ‘suicide mitigation’ rather than ‘prevention’ to move away from the notions of liability
and control. Mitigation involves carers and family members and places an emphasis on patient
collaboration.
In Scotland, the Choose Life strategy aimed to improve the

understanding of all types of front-line staff (Scottish Executive, 2002).
The advantage of using a shared training programme across all sectors, not
just health, was explained as being the creation of a shared value base that
recognised the range of socioeconomic, emotional and psychiatric factors
underlying suicide risk and would ensure continuity of approach and inter-
agency cooperation. This would be in addition to the specialist training for
health professionals.
A concerted programme of training of relevant statutory and related
services should be a component of national self-harm strategies. Education
providers, prison staff, staff in substance misuse services and those in social
work and housing provision are obvious examples.
Recommendations
•• The government department responsible for public health in each of the jurisdictions should lead
a cross-departmental strategy to raise awareness of self-harm, ensure appropriate training for
front-line staff in education, social work, prisons, police and other relevant agencies in dealing
with self-harm and to help fund and promote research into suicide and self-harm. A partnership
approach to implementation should be adopted wherever feasible and they should ensure that
government websites including NHS Direct and the Department of Health include authoritative,
accurate, accessible and user-friendly information on self-harm for service users, carers, family
members and friends.
•• The monitoring of harmful internet websites should be included in this strategy.
9. The role of the third sector
As already noted, people who engage in self-harm often do not come into
contact with statutory health or social care services, or at least not on
account of that behaviour. Many people who die from suicide have not been
in contact with those services prior to their death, and may never have
been a patient in respect of self-harming behaviour. This is particularly true
for young people and other special groups. In the case of older people,
self-harming behaviour may not have been detected by staff, although
actually young people are least likely to disclose it. Some people will,
however, have used third-sector services. Anecdotal evidence suggests that
statutory services can be difficult to navigate, stigmatising and place many
‘pre-requisites on people’, and that the third sector has had a substantially
greater role in dealing with these people as a result.
Self-help groups
There are also national and regional self-help groups throughout the UK,
some of which operate online (Box 9.1). Self-help groups have been found
valuable, in general and in relation to self-harm in particular (Smith &
Clarke, 2003; Mental Health Foundation, 2006). The NSHN (www.nshn.
co.uk) has built a network of support groups for individuals who self-
harm. It focuses on support and distraction, enabling people to seek
alternatives to self-harm. The charity aims to empower individuals to
explore reasons for their self-harm and to seek appropriate professional
help. It now equally supports friends, families and carers of individuals
who harm themselves. The NSHN also aims to raise awareness of self-
harm, underlying causes, triggers and the many ways to offer support.
Box 9.1 Example of a self-help group in the uk
•• YouthNet is an online charity that aims to provide young people with a safe environment and a
forum to discuss potentially difficult issues, including self-harm, and to exchange information.
The internet provides anonymity, reducing barriers to talking about issues, which is reflected in
the site’s popularity. YouthNet highlights and tries to address issues in the care available to young
people, which include mental health services having high thresholds to accessing services, thus
forcing patients to increase the severity of their behaviour in order to be seen.
•• In evidence to the Working Group, YouthNet indicated that it regards talking about issues as a
form of risk reduction for self-harm. It also trains its volunteers and monitors the posted material
to assess risk of negative material that may encourage or trigger self-harm. It highlights this as
a potential problem of unregulated sites, but generally takes the view that when people want to
talk, they want to be helped, which is positive.

They provide training to professional organisations, schools, universities,

charities and user groups. The charity runs an online support forum
serving over 2000 members.
‘I would like to see more local or an NHS local self-help support
group. You need to feel you are not alone. Online forums can be a bit
uncomfortable and you do not get to see anyone face to face. As they
are physical injuries, a support group face to face will help. You can
then understand and support others who do it, and it may help you
understand yourself and your reasons for self-harming. Such local
groups do not exist anywhere in the country it seems’. (N. Ali, personal
communication, 2008)
The Working Group heard evidence from the Samaritans and SANE
about their services. We give a brief account of their work to exemplify the
contribution of theirs (Box 9.2) and other organisations in the third sector.
Box 9.2 Voluntary organisations
•• The Samaritans operate throughout the UK and are one of the most widely known and regarded
voluntary mental healthcare providers. They provide 24-hour emotional support for callers and
respond to contacts by email and short message service (SMS). In their branches they have
face-to-face contact with clients. They carry out substantial outreach work in schools, prisons
and at festivals. In 2007, they had dialogue with individuals 2 700 000 times. They receive more
contacts identified to be from men (49%) than women (45%). They provide information, skills
development, and confidential and non-judgemental emotional support.
•• SANE’s national telephone helpline, SANEline, currently handles an average of over 2000 calls
every month from men, women and children affected by mental health problems as well as their
carers and health professionals. They undertake research and campaigns, making use of their
experience from the helpline and surveys.
Many other third-sector organisations provide services for people

who harm themselves. Evidence was provided to us by Rethink, Turning
Point and Mind, which all operate services of this kind. Turning Point, for
example, provides services particularly for people with dual diagnosis at
200 locations in England and Wales. Their telephone service operates 365
days a year. They provide solution-focused therapy for people who self-
harm, most of whom have substance misuse/use issues, and they assist
people with medical and other social needs. In evidence to the Working
Group they said that they offer long-term support to avert the need for
crisis behaviour.
There is clearly a role for engagement between the national third-sector
providers and government in policy and implementation, and there is some
evidence that this is not occurring in a widespread or systematic fashion.
The Samaritans in their evidence to the Working Group said:
‘An approach of partnership implementation, where particular
organisations are given responsibility for implementation in different
areas could be adopted. This approach was used in Scotland and is being
used in Wales, and resulted in key agencies, including from the third
sector, being given the resources and remit to drive forward action in
specific areas. For Mental Health professionals this approach is helpful
because it provides clarity on who is leading on key areas of work,
reduces confusion and increased the chances of engagement between
voluntary and statutory sector services. It also maximises the use of
services and resources that already exist rather than creating duplicate
services.’
The role of the third sector
Recommendation
•• Suicide prevention strategies and self-harm strategies should explore and strengthen the
relationships between third-sector and statutory-sector providers.

10. Research
Although suicide prevention has been the subject of much research in the
UK and overseas, self-harm as a distinct issue has received much less
attention until recent years. As a result, people who self-harm often do not
get the best care. Services and clinicians lack guidance as to what works,
and for whom, and commissioners lack evidence of outcomes to assist their
commissioning.
In England, research into self-harm, undertaken as part of the National
Suicide Prevention Strategy (Department of Health, 2002a) and through
the Oxford University Centre for Suicide Research and other research
organisations, has added significantly to the evidence base. Nevertheless,
research is still much needed into all aspects of the issue; epidemiological
studies, investigations of the full range of causes of self-harm, and, most
importantly, effective interventions to treat and to prevent self-harm.
It is evident from our discussion of interventions that a robust evidence
base is lacking for pharmacological interventions and for most therapies, in
particular family therapy, dialectical behaviour therapy, and psychodynamic
therapy, and for interventions such as harm minimisation. More research is
needed into the effectiveness of these and other interventions, such as CBT,
for particular groups.
The Scottish review (Leitner et al, 2008) also identified a need for
research into ‘interventions which may be effective for the general population
or for specific populations other than people with depression or borderline
personality disorder’. They also state that given some evidence for the
effectiveness of ‘relatively simple interventions’ such as providing a person
with ongoing contact and support, ‘future research would benefit from
going “back to basics” and exploring in greater depth this type of minimalist
approach’. This is currently being investigated by researchers in Manchester,
Bristol and Oxford.
There needs to be more research into issues of service provision, for
example whether dedicated self-harm services deliver better outcomes. The
specific correlations and relationship between self-harm and suicide and drug
or alcohol addiction, together with interventions and services for this group
of people, is an area that has been neglected.
There is also a lack of knowledge of longer-term outcomes from
service-user perspectives. Their lived experience of pathways into and out
of self-harming behaviour focusing on what they say has worked for them
should be researched. The experience of carers has also been neglected.
They should be studied, both in their own right and regarding the insights
into self-harm they have gained from the experience and knowledge of
people they have cared for. Other priorities for research were identified by
members of the Working Group and include the following.
Research
Prospective and case–control research studies of self-harm in the

community would help to address the many gaps in our knowledge.
Effectiveness and economic evaluation of mandatory training for front-
line health workers, taking into account direct costs of repeat self-harm
and indirect costs.
How self-harm is dealt with in primary care, including issues of
attitudes and training.
The role of nurses, the tools they use and the problems they encounter
with patients who self-harm.
Cost–benefit analyses of assessments and interventions for self-
harm.
Research into causes of self-harm, including biological, psychological
and social causes and their interactions.
Better evidence base for treatment of those with an intellectual
disability or autism-spectrum disorder.
Development of triage tools and their evaluation.
Interventions for those bereaved by suicide.
Studies of the role and experiences of carers.
There is no point in government and others calling for evidence-
based practice unless the research is in place to develop and evaluate the
evidence.
Recommendation
•• A combination of national government funding streams, medical research council/economic and
social research council funds, and charitable funds should consider research into self-harm as a
funding priority.

Part III
Working with individual people
11. Introduction
The NICE guidelines on self-harm (National Collaborating Centre for

Mental Health, 2004) address the short-term physical and psychological
management and secondary prevention of self-harm in primary and
secondary care, providing guidance, not only on services but on good
practice in dealing with individual patients. A second NICE guideline is under
development. It will cover the medium- and longer-term care management
of people who self-harm, as well as their ongoing psychosocial assessment,
psychosocial and pharmacological interventions for the specific treatment
of self-harm, safe prescribing, treatment of people with specific care needs
and special techniques (e.g. harm minimisation), and training for healthcare
professionals treating people who self-harm. Other relevant NICE guidelines
include those for borderline personality disorder (National Collaborating
Centre for Mental Health, 2009a) and depression (National Collaborating
Centre for Mental Health, 2009b).
The College document, Assessment Following Self-harm in Adults
(Royal College of Psychiatrists, 2004) identifies consensus standards
for assessment following self-harm. Competencies expected of both
generalist and specialist staff are identified. Standards are described for the
organisation and planning of deliberate self-harm services, procedures and
facilities, training and supervision. These are specifically described for A&E,
the general hospital, the community setting and the psychiatric in-patient
unit. More detailed advice is given regarding particular patient groups: the
patient who is intoxicated, the patient who repeatedly harms themselves and
the patient who is reluctant or appearing to refuse intervention. The specific
risks associated with older adults are also highlighted. Managerial standards
are suggested for a self-harm planning group or coordinator.
The Working Group was keen to gain an insight into how policies and
standards were actually implemented, not just at the macro-level but in the
experience of psychiatrists and others who deal directly with individuals in
need, as well as the service users themselves and their carers. A Members’
survey was conducted and this provided useful data (Appendix I). Selections
from this survey are quoted in the report.

12. Overarching themes
The role of psychiatrists and other healthcare

professionals
Psychiatrists and other colleagues in health services are not only involved in
policy and service development but in working directly with individual people
who have harmed themselves, or are at risk of doing so. However, given the
wide spectrum of behaviour and the multiple causes for it, the extent of their
role varies (Box 12.1).
Box 12.1 A liaison psychiatrist’s response to the College Members’ survey
The groups we see across our three acute [A&E] sites in North London are roughly as follows.
•• Essentially one-off self-harm in response to stress; usually a small overdose, no evidence of

mental illness, often embarrassed by what they’ve done, unlikely to attend follow-up appointment
(we tried it >85% DNA rate) and not really suitable for home treatment team or CMHT, therefore
the majority are referred back to general practitioners (GPs).
•• Repeat self-harm, usually in response to something/somebody destabilising their mental state,
established diagnosis of emotionally unstable personality disorder, usually already linked in with
CMHT, psychology or personality disorders service.
•• Repeat self-harm or suicidal threats when intoxicated, sometimes under Section 136, often
presenting dramatically, usually no fixed abode or out of area, rarely other psychiatric comorbidity
apart from dissocial personality, usually discharged when sober with no follow-up.
Most clinicians working in general hospital practice will primarily

see patients who have taken overdoses, while in community practice and
mental hospital in-patient facilities there will, in addition, be a substantial
number, especially young people and those with disturbances of personality,
with a history of cutting or mutilating themselves. There is evidence that
most general practitioners treat patients in their own homes following self-
harm, provided there is no risk to life (Dennis et al, 1990). In many cases
seen in general practice, self-harm could best be regarded as an episode
in the long-term treatment of a patient who requires support services and
interventions configured from within general practice (Poustie & Neville,
2004).
There is evidence that hospital services offer less to people who have
cut themselves, although these individuals are far more likely to repeat
their actions than are those who have taken overdoses of drugs. They
are less likely to receive a psychosocial assessment or to be admitted to
Overarching themes
general hospital. This appears to reflect a mistaken view that this behaviour
necessarily reflects a low level of suicidal intent, with a lack of understanding
that people may switch from cutting themselves to poisoning themselves
(Lilley et al, 2008).
In the College Members’ survey, most respondents (71%) agreed
that they had a role in managing people who harm themselves, with higher
numbers of those in forensic and addiction services (85%) and lower
numbers of those in A&E departments, where they are more likely to see
patients with a lower rate of mental illness.
Participants stressed the important role of experienced psychiatrists
to deal with the complex nature of self-harm. It was emphasised that they
were needed to assure appropriate screening and signposting to treatments
when they are needed (see below).
‘I have seen several completed suicides (can provide details) in medical
negligence cases where social workers and the like have performed
(incorrectly completed) liaison risk assessments and discharged patients
to kill themselves. Also seen people who self-harm (including one man
who had tried to gas himself) inappropriately managed by CMHT by
deferring discussion of the case until a multidisciplinary team meeting
the next week … or another male self-harmer admitted to an experimental
unit with no nursing staff or observations, who hung himself within
hours. There is a real crisis in getting these patients properly and swiftly
assessed by the most competent members of the team and then getting
them the appropriate management, e.g. admission if necessary … The
College MUST highlight these problems more ... or else it will be seen as
a complacent accessory to these tragedies.’
On the other hand there was concern that their role in ongoing
management should not be overstated. People who have harmed
themselves, but without an indication of underlying significant mental
illness, should generally be discharged to primary care, where they
should be assisted to address their life and relationship problems and not
be encouraged to see their problems as evidence of illness. Sometimes
psychiatrists took on too much of the burden when the person should
rather have been referred to social, psychotherapeutic or other services.
Members also emphasised that psychiatry should also be clinically driven
rather than risk driven.
‘I don’t think it helpful to regard all self-harm as due to mental illness.
Some of these patients would not reach the threshold for any diagnostic
category of illness, yet they are usually very angry, and often chronically
deprived and miserable too with few other methods of dealing with their
lives. This is not about ‘labelling’ but about recognising the nature of the
problem, which is always psychosocial, which leads to a more helpful
clinical approach.’
Some participants even felt that the intervention of psychiatrists could

make the situation worse.
‘We clearly have a role in helping people to understand why they self-
harm and, if a treatable mental disorder is present, to ensure that the
patient is receiving appropriate treatment. However, inappropriately
labelling someone’s behaviour as stemming from an ‘illness’ can
undermine the person’s autonomy in managing their behaviour.’
The perception that self-harm is not necessarily the province of

psychiatrists may also reflect changes in practice, the emphasis on risk

included, that appear to have narrowed the focus of psychiatric practice and
devalued the therapeutic relationship.
On the other hand, Good Psychiatric Practice (Royal College of
Psychiatrists, 2009b) makes clear that where the psychiatrist is involved,
their role includes establishing and maintaining a therapeutic alliance with
the need for the psychiatrist to be competent in obtaining a full and relevant
history that incorporates developmental, psychological, social, cultural
and physical factors, and to be knowledgeable about the social and life
experiences of their patients.
The College Members’ survey

The survey of College members was not able to give a full account of the
extent of the problems that they encountered, their settings or geographical
spread. However, the survey provides a snapshot with common themes and
issues that are consistent with other surveys, academic research and service
users’ reported experience. Respondents’ accounts chime with these other
accounts, although overall they rate their services more positively than
service users do.
Individual respondents expressed considerable concern and frustration
about a range of issues concerning the care that vulnerable, sick people
could expect to receive.1 This was frequently linked to a lack of resources
and pressures of busy work places.
‘How many patients get admitted to general medical wards following self-
harm, and then self-discharge – sometimes with tragic results – following
a brief (if any) conversation with a very junior psychiatrist. It is alarming
how easily someone with very severe, but possibly as yet undiagnosed,
mental health problems, following a very serious suicide attempt, can
leave the medical wards with no clear management plan – and everyone
turning a blind eye owing to other pressures/lack of training.’
Another respondent to the survey made a pithy statement of what they

thought was needed.
‘The public affirmation of the extreme importance of self-harm as a
signal of likely impending suicide and the prevention of suicide as a
national goal. The statement of self-harm as vital an indicator as chest
pain or stroke or a 4-hour breech as a presentation at A&E settings and
the requirement of primary care trusts to commission for self-harm as
they do for acute stroke and chest pain.’
In their detailed comments, psychiatrists raise problems they

particularly face in dealing with self-harm, including:
insufficient appropriate training for staff, including psychiatrists
inexperienced staff put in charge, especially out of hours
lack of attention to self-harm by senior clinicians
a culture that puts too much emphasis on risk assessment
insufficient evidence for what treatments work
lack of available psychological therapies.
1. See qualitative data in Appendix I.
Overarching themes
This all has immediate implications for patients’ recovery and for
long-term costs in the healthcare system. Although most evidence relates
to emergency care, similar pressures apply to acute in-patient wards and
CMHTs. However, presentation at hospital will often be the first time that the
person who is harming themselves will have had contact with psychiatric
services. Failure to deal effectively with people who harm themselves or
attempt suicide is a major cause of hospital in-patient admissions and the
seriousness of this is often overlooked by hospital management.
The question of resources

The problem of resources underlies some of the shortcomings the College
Members identified.
‘In my Trust there is a block on further development for financial reasons
and services are underdeveloped, so there is an incomplete self-harm
pathway. There is therefore a gap between aspirational strategy and
resources available. This leads to problems with training and for staff
trying to help distressed people without appropriate resources. Hence
staff, particularly those working from a narrow biomedical model, will
dismiss patients, which may at least be honest, rather than offering an
inadequate service, which can make things worse.
There is an urgent need for an improvement in the NHS standards

of care for people who have harmed themselves and who receive care in
A&E departments and in hospitals; there is less information about how well
people are managed and treated in the community. In a period of austerity in
the NHS there is an evident danger that substandard care will become more
widespread, thereby creating, for the long term, more expense and strain
on services because of untreated illness.
Compliance with NICE guidelines

Having regard to NICE guidelines is now a legal duty on the NHS under the
NHS Constitution (Department of Health, 2010):
‘Nationally approved treatments, drugs and programmes: You have the
right to drugs and treatments that have been recommended by NICE
for use in the NHS, if your doctor says they are clinically appropriate
for you.’
Two-thirds of respondents reported having read the NICE guideline on

self-harm, with the lowest number being those working in addictions (50%)
and the highest in child and adolescent settings (86.6%).
Psychiatrists rated the performance of the service settings in which
they work in accordance with six aspects of service provision as specified
by NICE (National Collaborating Centre for Mental Health, 2004). Across
all six items, most considered that performance was good or very good;
the lowest rated performance was information provision, where 67% rated
it this way. Across the main psychiatric specialties, greater dissatisfaction
was, on balance, voiced by those in liaison, learning disability and old age
services. Furthermore, trainees rated services less highly than consultants.
Those working in child and adolescent services had the highest level of
satisfaction.

13. What do service users
and carers want from services?
Evidence from service users

The first contact that a person who harms themselves makes with NHS
services will occur in a variety of contexts and settings – through ambulance
services, an A&E department, a GP surgery, at a general hospital, as an in-
patient in a psychiatric facility, at a community-based mental health service,
in prison, in residential care or in a children’s home. The person’s actions
may bring them to the attention of the police and to a place of safety. How
they fare in this first contact is vital. The attention they get at this contact
may determine the quality and continuity of care they receive from then on,
and it may well determine their response in a later crisis. Good care at this
stage may also encourage further willingness to seek help when needed,
improve quality of life and may contribute to their overcoming the problem
behaviour. It may reduce the need for hospital admissions.
There are numbers of studies of service users’ views and experiences
of contact with health services after self-harm (Horrocks et al, 2005; Platt
et al, 2005; Mental Health Foundation, 2006; Broadhurst & Gill, 2007; Royal
College of Psychiatrists, 2008b; Heslop & Macaulay, 2009). They emphasise
that above all, people need an empathic non-judgemental approach to their
self-harming behaviour, based on understanding the issues involved and the
functions self-harm may fulfil for the individual. What is most helpful is a
relationship in which they are ‘listened to and supported not judged, where
the boundaries are clear and where those relationships can support them
over a long period of time’ (Burke et al, 2008).
‘I think the main thing that’s helped me reduce my self-harming is the
ability to talk about my feelings; I’ve never been able to talk to anyone
before about my feelings. I’ve had help through psychiatric services
but they don’t seem to understand and [they] judge and label you, and
there is always the fear that if you say the wrong thing they’re going to
lock you up.’
Service users can find it difficult and distressing to talk openly to

someone they do not know. The stigma of self-harm may inhibit them.
They may fear that discussing their problems will intensify their distress
by bringing back repressed memories. Service users need to trust and also
to feel safe in disclosing painful personal issues. Cultural expectations and
negative previous experiences can also be inhibiting.
What do service users and carers want from services?
Rather than being expected simply to stop harming themselves (which

is seen as very unhelpful) people who self-harm value assistance with
successful distraction techniques and alternative coping mechanisms. They
seek help to acquire skills and information that give them greater choices
and control. They also need support to improve their mental resilience.
Providing reasonable hope for recovery from their distress should be a
routine part of their care.
A person who attends hospital will need their distress acknowledged
as well as prompt attention to their physical care, but for busy healthcare
staff having to switch from physical care to mental health needs can be
challenging. Timely provision of information about their treatment and good
communication are helpful. However, having their views taken seriously,
participating in decisions about their care and treatment, and having
clear explanations for decisions are highly rated (Taylor et al, 2009). A
willingness or ability to accede to cultural requests, including preferences
as to the gender of staff, makes a big difference, as does a sensitivity
to, and understanding of, the social context that has contributed to the
behaviour.
It would appear, however, that although service users give some
reports of good care, these basic needs are not being routinely met.
Problems experienced
The NICE guideline reports many service user concerns over the services that
they receive, including the attitudes of staff (National Collaborating Centre
for Mental Health, 2004). Those who present at A&E are often put low on the
triage scale and have to wait while ‘more important’ patients are dealt with
first (Taylor et al, 2009).
‘The result of this is that 43% of service users said that they had avoided
emergency services in the past because of previous negative experiences
and the same number had avoided services for fear of being detained
under the Mental Health Act.’ (National Collaborating Centre for Mental
Health, 2004: p. 112)
A systematic review of the international literature on service users’

experiences at A&E departments concludes that poor communication
between patients and staff and a perceived lack of staff knowledge with
regard to self-harm are common (Taylor et al, 2009; see also Broadhurst &
Gill, 2007). The College project Better Services for People Who Self-harm,
a survey of 509 service users’ experience of emergency services following
self-harm, had similar findings (Royal College of Psychiatrists, 2008b). The
attitudes and behaviour of staff were the most significant factors affecting
experience of care and their ability to cope once leaving the emergency
service. Some respondents to the survey recalled being told that they were
wasting time and resources. This compounded their distress and led them
to discharge themselves prematurely.
Some service users felt that the initial and psychosocial assessment
placed insufficient emphasis on their own views and needs. Some also
considered their physical care was inadequate, especially that pain relief
was not provided. A previous negative experience had deterred 35% from
seeking appropriate help and for some this meant that they were less able
to access an assessment and potentially helpful interventions.

Two contrasting observations were:

‘The doctors and many of the nurses and other staff in this department
seem well informed and are obviously trying to provide a non-
judgemental professional caring service for people who have self-
harmed.’
‘It was an awful experience I would rather die than go back there.’ (Royal
College of Psychiatrists, 2008b)
These findings are consistent with those from other service user
surveys. Truth Hurts, reporting on the experiences of adolescents states that
many young people complained that A&E staff ignored their mental state,
concentrating entirely on their physical problems.
‘On the occasions I have been admitted to an A&E department they have
concentrated on medically patching me up and getting me out. Never
have I been asked any questions regarding whether this is the first time
I have self-harmed or if I was to do it again or how I intend to deal with
it.’ (Mental health Foundation, 2006)
It is likely that in respect of other matters such as lack of privacy,

long waiting times and superficial contact with busy staff, the experiences
of people who self-harm are not different from others who attend in an
emergency (Horrocks et al, 2005).
Carers
There is a lack of information about the views and needs of carers of people
who self-harm. Carers may feel isolated, stigmatised and burdened with
the anxiety of caring for a family member or friend who repeatedly harms
themselves. Their own feelings, especially feelings of shame, may be
exacerbated by their cultural environment or their religion.
Friends and relatives can play a crucial role in the care and treatment
of people who self-harm. They can provide emotional, practical and financial
support and encourage people to seek appropriate support and treatment.
They can become involved in treatment plans and, above all, make the
person feel wanted, needed and loved. In surveys of people who self-harm,
carers are seen as more helpful than professionals and by many as the main
source of support.
It is important to recognise that friends and family are not always
helpful or healthy in their relationships with service users; however, where
carers have been identified and service users are willing to involve them,
they should be part of the process from the outset. They should also be
offered a carer’s assessment at the first point of contact if the service user
agrees.
Professionals should regard it as automatic to enquire about the service
user’s carer and the level of involvement that they would like to see from
them. If there is a joint agreement that the carer be involved, they should
be kept informed on situations that concern them, especially when it directly
relates to their care giving. Important issues of confidentiality will apply
but aspects of care that will involve the carer should be openly discussed.
Carers bear a lot of responsibility and when the relationships are positive
can have a profound impact on good recovery outcomes. As far as possible
What do service users and carers want from services?
and appropriate they should be included as part of the team and respected
for their expertise and knowledge.
The NICE guidelines on self-harm (National Collaborating Centre for
Mental Health, 2004) make recommendations for professionals to work with
carers of people who have self-harmed (Box 13.1). These envisage that
carers will play a direct role in the care of the service user.
Box 13.1 Recommendations for professionals working with carers
•• Key objectives in treatment of self-harm should include effective engagement of service user
and carer where appropriate (p. 29).
•• Healthcare professionals should provide emotional support and help to carers and relatives as
they may also be experiencing high levels of stress and anxiety (p. 51).
•• Carers may need advice on risks of self-poisoning (p. 63).
•• Carers might be part of harm minimisation techniques and alternative coping strategies
(p. 64).
•• Initial management of people who repeatedly self-harm should include advising carers of the
need to remove all medication and objects that could be used for self-harm (p. 68).
•• Carers and relatives of service users should be enabled to accompany them to appointments
and treatment (p. 83).
Page references within National Collaborating Centre for Mental Health, 2004
Although respondents to the College Members’ survey reported

positively about the level of involvement of carers in their service there is
little direct information about the views of carers themselves. A College
Report from the College Centre of Quality Improvement on the performance
of 112 acute in-patient mental health wards for working-age adults
(Cresswell & Lelliott, 2009) reported that a substantial minority of carers
(about 40%) had not been offered an interview with staff or a carer’s
assessment and a third had not been able to engage meaningfully with
the process or the patient’s discharge. We recommend above (p. 59) that
research into the role and experiences of carers is needed.

14. The College Members’ survey:
skills and services needed
The evidence of healthcare professionals and service users’ and carers’

experience of the service has been referred to in the previous chapter. In this
chapter we consider it in more depth, looking specifically at what the College
Members’ survey told us about the skills and services that College Members
believe are required for professionals engaging with and undertaking
assessments and management of patients who self-harm and patients who
are suicidal.
Staffing issues
Staff attitudes and training

Staff views on this issue have complemented those of service users. For
example, the College project Better Services for People Who Self-harm
found that 26% of staff felt that they did not know enough about self-harm
to communicate effectively (59% of staff in the A&E department), and 35%
of staff felt that those who self-harm regularly were not treated as well as
those who have done so only once (Royal College of Psychiatrists, 2008b).
The project concluded that increasing staff understanding can be achieved
relatively easily by giving staff more information on why people harm
themselves and suggestions as to the best response. Involving service users
at an early stage of planning and training is hugely beneficial in improving
services.
The problem of staff attitudes to self-harm has been the subject of
many studies in the UK and overseas. Overall, they show that large numbers
of healthcare staff have a profoundly negative reaction to patients who
harm themselves (Patel, 1975; O’Brien & Stoll, 1977; Creed & Pfeffer 1981;
Crawford et al, 2003), compared with those with physical illness, and that
this is likely to be reflected in the quality of clinical care. The attitudes were
most pronounced in general medical settings, where patients were often
seen as time-wasting. There appears to be a more sympathetic attitude to
those who have a mental illness and those who were clearly suicidal at the
time. Those who repeatedly self-harm are less well regarded (Mackay &
Barrowclough, 2005).
A study of school nurses within one UK primary care trust reported
that nurses felt frustrated and inadequate when working with young people
who self-harm despite the training many of them had received (Patterson
et al, 2007a; Cooke & James, 2009). This study concluded that self-harm
training for school nurses needed to incorporate both practical approaches

and theoretical knowledge. Another study linked negative perceptions to their
lack of knowledge, their qualifications and their general level of experience
(Wheatley & Austin-Payne, 2009).
Respondents to the College Members’ survey noted that staff
consider self-harm challenging to manage because they have a limited
understanding of it. As a result some people who need the most help are in
danger of being excluded. We were also told in evidence from Choose Life
(Scottish Executive, 2002) that psychiatrists also often feel uncomfortable
with patients who have attempted suicide, and they hesitate to ask simple
questions about the patient’s motivation. One respondent to the College
Members’ survey gave the view that:
‘although suicidal intention is not commonly reported, very many of
the young people we see agree that they were suicidal for a moment at
the time of the overdose (we are not talking about cutting here). It is a
good idea to ask about this, because it is a relief to the patient to have
his or her despair acknowledged even if it has to some extent lifted.’
Two contributors2 said that the difficulties that a suicidal or self-
harming patient may present to staff were due partly to the person’s complex
motivation (e.g. an ambivalence about dying) and partly to the aggression
and anger they may display towards staff who are trying to assist them.
Outlining a psychoanalytic understanding of the issue, they emphasised the
central importance of the therapeutic alliance with the clinician and the need
for the clinician to go beyond a ‘medicalised and sanitised’ interpretation
to one that recognises the nature of the destructive forces underlying
the patient’s behaviour. Only in that way can the clinician achieve some
understanding of what the behaviour means for that person. In their view,
training must also address these deeper issues to provide staff with the
confidence and competence they need.
The NICE guideline (National Collaborating Centre for Mental Health,
2004) states that:
‘clinical and non-clinical staff who have contact with people who self-
harm in any setting should be provided with appropriate training to equip
them to understand and care for people who have self-harmed.’
The impact of staff training on attitudes has been evaluated and both
general hospital and psychiatric staff have reported significant improvements
in attitudes and confidence (Turnbull & Chalder 1997; Samuelsson & Asberg,
2002; Patterson et al, 2007b; McAllister et al, 2009) after their training.
Given that there is a rise in the incidence of self-harm and that in-patient
beds in psychiatric wards have declined, given also that more mental health
issues are dealt with by GPs, primary care training programmes need to be
targeted at doctors. ASIST and similar programmes are a useful introduction
to self-harm, but a more sophisticated training programme is essential for
health and mental health professionals. This needs to address knowledge of
self-harm, attitudes, communication and clinical issues such as assessment
and management. A standard national programme would provide greater
consistency.
2. Dr Robert Hale and Dr Don Campbell the Portman Clinic, London, UK.

Recommendation
•• The Royal College of Psychiatrists works with colleagues in other health disciplines and other
relevant partners to develop a common curriculum on self-harm for front-line health professionals
and that Trusts and Health Boards provide time for staff regularly to receive this training.
Training on psychosocial assessments

Fewer than 50% of respondents to the College Members’ survey considered
that they (or their team) had the training to undertake psychosocial
assessments of risk and need with people who had harmed themselves.3
The highest percentage of those who have been trained were in liaison
settings (62.7%). Over two-thirds of the 85 psychiatric trainees and
doctors working in A&E departments rated their training in conducting
psychosocial assessments as ‘insufficient’ (Royal College of Psychiatrists,
2008b). Respondents expressed dissatisfaction with the expertise of
their own profession of psychiatry and with other staff – nurses, doctors,
social workers, pediatricians, police and prison staff. Dissatisfaction was
also frequently voiced about the fact that junior staff were undertaking
assessments without the requisite skills or experience.
‘I also think that in some services junior psychiatrists do not get much
training, during normal working hours, of the assessment of self-harm
and are expected to undertake this work out of hours or in some cases
not at all. It should be a requirement of psychiatric training and not just
left to nursing staff.’
When asked if they had received a psychosocial assessment, 62%

of service users replying to the College survey said yes (Royal College of
Psychiatrists, 2008b), although a third were dissatisfied with the quality of
assessment they had received. In some cases, service users felt that the
assessment was something that was ‘done to me, rather than with me’.
Fully involving the person who harms themselves in discussions about their
problems and future care is essential.
Junior staff
Some participants in the College Members’ survey questioned whether
junior psychiatrists and trainees should be entrusted with the assessment
and management of self-harm. Such responsibility, including whether to
discharge the patient, sometimes rested with them. This is partly due to
the fact that most incidents occur after hours, when junior staff are the only
ones on hand.
‘In terms of our service, weekends and nights there is one psychiatry
trainee covering apparently the largest A&E in the UK and the rest of
the teaching hospital. We hardly ever do joint assessments with crisis
3. In total, 25% of those in learning disability, 44% in rehabilitation, 47% in old age and 48% in general
adult reported this. However, the large majority of psychiatrists reported agreeing or strongly agreeing that
they had been provided with the training to explore with the patient the underlying causes of their self-harm
(82.4%). Unsurprisingly this was most evident in those working in academic settings (73%) or where their
main psychiatric specialty was psychotherapy (92.1%). Only learning disability reported a lower proportion
(67.3%).
resolution team owing to their unavailability ... As a trainee it can feel

quite overwhelming at times … a patient has waited 8 hours and there are
then two or three phone calls interrupting the assessment.’
‘Junior doctors see more self-harm than all the other cases put together
when on call. I would estimate that 90% of the patients I saw out of
hours were self-harm. This is strenuous, repetitive and puts people off
doing psychiatry.’
‘As a junior doctor I was often left with the responsibility to deal with
deliberate self-harm on my own when on call outside hours. This
certainly helped to burst my confidence in assessing such behaviour
but the risks became diluted with the crises and home treatment team
input ... The issue is often how to provide a safe plan with significant
scarce resources.’
The European Working Time Directive appears to have created

particular staffing problems at night.
‘Junior doctors’ shift work patterns now rely heavily on high standards
of hand-over to ensure that the necessary after-care arrangements are
made for any patients seen in emergency care following an episode of
self- harm. This standard tends to diminish where there are high rates of
locums or junior doctors from dispersed sites.’ (Pitman & Tyrer, 2008)
Others believed that trainee psychiatrists are being deprived of the

training opportunities they need. It was suggested that senior psychiatrists
were not taking enough of a role and the implications for the quality of care
were obvious.
‘Self-harm appears to me to be an area of psychiatry that is neglected
by senior medical staff. Generally, nurses or very junior psychiatrists
carry out assessments, often alone. This has implications for the physical
safety of the assessor and influences the quality of the assessment. It is
unclear why people who self-harm seem to be screened out from senior
psychiatric input in this way.’
‘Often pressure is put upon psychiatric juniors/liaison teams to see and

discharge patients quickly rather than giving the patient the respect of
giving them some time (where appropriate) to be psychologically ready
to discuss their reasons for self-harm.’
A recent review of an A&E department in North Wales makes similar

findings (Jones & Avis-Jones, 2007).
Other views underlined the value, as we stated above, in having
experienced clinicians, including psychiatrists, directly involved in assessing
and treating patients who self-harm from the outset, given the complex
nature of these cases.
Liaison psychiatry services

Respondents to the College Members’ survey and other evidence received
from the College Faculties emphasised the need for better access to liaison
psychiatrists and higher levels of funding. The lack of paediatric liaison
services and those specialising in the care of older people was also raised.
The decline and closure of comprehensive liaison psychiatry services and
poor commissioning of liaison psychiatry services was cited as a pressing
problem, as it had been in the Academy of Medical Royal Colleges (2008)
report. The report recommended that:

‘Patients in the acute hospital should have the same level of access
to a consultant psychiatrist as they would have from a consultant
specialising in physical health problems. Ideally liaison services across
the country should be developed so that a consultant liaison psychiatrist
is available.
Acute trusts should be commissioned to ensure provision of Acute Care

Liaison Psychiatrists.’
Department of Health guidance provides that the A&E response should

be delivered by liaison psychiatrists, not crisis teams (Crompton & Daniel,
2007). Liaison psychiatry services are in an ideal position to: educate and
support other mental health colleagues in self-harm; ensure a more effective
and efficient service to patients who self-harm; and save duplication of work
by other staff. The involvement of liaison psychiatrists in training also needs
to be supported by Trusts.
Roles in multidisciplinary teams

The opportunities and challenges of multidisciplinary teams were also raised.
On the one hand it was agreed that psychiatrists should certainly not be seen
as the only people who can assess and help people who harm themselves,
but on the other hand practice in these teams could give rise to concern if
there was not senior psychiatric supervision. Some questioned whether all
mental health staff had received the right professional training to acquire the
skills that were needed.
‘Increasingly with New Ways Of Working ... the multidisciplinary team are
expected to manage many such complex cases relatively independently,
referring to consultants only for “supervision or support” as they see fit.
I have been concerned to discover cases when in my view the risks of
harm to patients have not been recognised by team members ...’
It is clear that a greater attention to the issue of self-harm is required

overall. Training and management practices need to be re-examined
and changed to ensure that regular training of staff, especially junior
psychiatrists, occurs and that appropriately trained staff are available.
The Working Group believes it is vital that these issues are addressed
by Trust management and commissioners. In essence, although service users
are calling for more empathic consideration of their case, the healthcare
system is operating in a way that makes this almost impossible for staff to
provide. Some respondents questioned whether this level of care would be
deemed acceptable in relation to physical crises.
Recommendations
•• The Royal College of Psychiatrists should ensure that training in psychosocial assessment and
management of self-harm should be a core competency for all junior psychiatrists. It should be an
essential component of prequalification training.
•• Trust management should ensure that junior doctors are exposed to people who harm themselves
but with access to supervision on a regular basis with senior staff. Staffing schedules should ensure
that senior clinicians are involved in supervising or managing cases of self-harm from the outset.
•• Commissioners of mental health services and Trust managements should make liaison psychiatrists
available for A&E and general hospital wards at all times and they should be there to provide training
and support for colleagues dealing with self-harm.
Staff supervision, support and management

The burden placed upon junior staff, including psychiatrists and trainees, to
assess and deal with the majority of self-harm presentations raised the issues
of supervision and support for staff. Evidence to the Working Group called
for more support to be given to staff who work in an environment where
they are more likely to encounter this behaviour as it can be detrimental
to their mental well-being. Staff cited the negative feelings associated with
treating a person who has repeatedly self-harmed. They reported that they
felt frustrated and had a sense of failure with such patients because of
their perceived inability to treat the causes of self-harm – only the results
(National Collaborating Centre for Mental Health, 2004). The need for support
for staff has featured in other studies (Thompson et al, 2008). It was noted
that patients with intellectual disabilities are often a particular challenge
for front-line A&E staff owing to difficulties in communication and errors of
attribution.
One participant noted that other agencies, including social care and
even child psychology, refer patients as soon as possible to child and
adolescent mental health services (CAHMS) to reduce their own anxieties
about the patient.
‘I see CAHMS as often being put in a position of handling/soaking in the
anxiety of other agencies/professionals. I think that there is a burning
need to train professionals about the mechanisms/theory of self-harm and
suicide and the difference between the two. We provide a consultation
service for professionals to try and contain their anxieties about self-harm
and therefore enable them to continue working with the patients.’
The NICE guideline states:

‘Providing treatment and care for people who have self-harmed is
emotionally demanding and requires a high level of communication skills
and support. All staff undertaking this work should have regular clinical
supervision in which the emotional impact upon staff members can be
discussed and understood.’ (National Collaborating Centre for Mental
Health, 2004)
The important role of reflective practice in supervision and support was

raised by the College Psychotherapy Faculty. This is considered below.
Recommendation
•• There must be an improvement in the culture of practice to ensure that organisations support
mental health professionals and promote good patient outcomes for those who have harmed
themselves. Clinical staff should have sufficient support from colleagues available to them. Reflective
practice should be embedded into supervision and into organisational practice.
Assessments
Risk assessment
The NICE guidance requires risk assessments to be undertaken (National
Collaborating Centre for Mental Health, 2004).

‘All people who have self-harmed should be assessed for risk: this
assessment should include identification of the main clinical and
demographic features known to be associated with risk of further
self-harm and/or suicide, and identification of the key psychological
characteristics associated with risk, in particular depression,
hopelessness and continuing suicidal intent.’
Participants raised similar concerns about risk assessment as those

voiced in a previous College (Royal College of Psychiatrists, 2008a). That
report had discussed the impact of the blame culture on mental healthcare
that had led to an overemphasis on risk assessment, with the underlying
fallacious assumption that, properly undertaken, risk assessment could
predict future events such as homicide or suicide, or repeat self-harm.
Academic research provides evidence for the limited role that risk assessment
can play in predictions of risk (Shergill & Szmukler, 1998; Powell et al, 2000;
Coryell & Schlesser, 2001; Szmukler, 2003; Undrill, 2007).
Professor George Szmukler presented to the group research on the
effectiveness of risk assessment tools. The conclusion was that the prediction
of suicide and the assessment of suicide risk in respect of any individual
patient is virtually impossible. The rates of suicide on a national scale are
predictable; however, this does not translate into being able to predict who
is likely to die by suicide, only that someone is. Any useful assessment,
in his view, is better done without the complexities arising from elaborate
tools but should instead be based on more efficient and smaller tools or on
psychosocial assessments (G. Szmukler, personal communication, 2009).4
Another expert said that, in her experience of working in a dedicated self-
harm service, the prediction of self-harm or suicide was only accurate for up
to one week ahead (L. Gask, personal communication, 2009).
The College Report states (Royal College of Psychiatrists, 2008a):
‘Risk management is a core function of all medical practitioners and
some negative outcomes, including violence, can be avoided or reduced
in frequency by sensible contingency planning. Risk, however, cannot
be eliminated. Accurate prediction is never possible for individual
patients … because of the multiplicity of, and complex interrelation of,
factors underlying a person’s behaviour.
This concern with risk, instead of stimulating better and safer practice,
appears to have had a negative impact on mental health professionals,
professional practice, service users and the public.’
Respondents to the College Members’ survey voiced similar views,

believing that positive risk taking and overall patient well-being were both
jeopardised by defensive practice arising from the preoccupation with
risk assessment. Use of separate risk assessment tools is dangerous as
overreliance on them too easily leads to complacency and can misdirect
people into thinking that there is a short-cut to assessment that ignores
detailed history and mental state assessment and the need to synthesise a
detailed clinical formulation based upon these.
The majority of respondents were critical of risk assessment
instruments premised on ‘tick box’ assessments. These were seen as
bureaucratic or defensive tools employed by their organisation. This was
4. Part of a PowerPoint presentation to the Working Group, ‘Predicting suicide – a rare event’, given
at The Royal College of Psychiatrists, September 2009.
also sometimes associated with the move towards junior and non-medical
staff undertaking assessments. It appears to apply to community as well
as in-patient settings. A key concern was that clinical skill and nuance was
being overlooked.
‘In our service, the junior doctors must complete vast amounts of
paperwork for each person they see in A&E with self-harm. There was
also talk recently of introducing a further ‘tick-box’ questionnaire for
patients about their intentions and suicidal behaviours.’
‘… in our wish to minimise risk we can veer towards introducing more
and more forms and questionnaires to document risk, which may help
us to feel better, but which actually take time away from talking with the
patients and helping them.’
‘I do not agree with the actuarial ‘paper-pushing’ way that risk

assessments seem to be taken out by CMHTs – in my experience they
give little clinical information of relevance. I have seen several near
misses by multidisciplinary team members overconfident in these
blunt ‘tools’; they feel that if they are trained to tick some boxes, this
means they are trained to undertake sometimes complex assessments
which require a full psychiatric understanding of the patient and their
situation.’
The Working Group concluded with a concern that the endemic tick-box
mentality removed staff from people, devalued engagement and impaired
empathy. Empathic listening and talking have key therapeutic benefits.
The best risk assessment is done not by filling out a pro forma but by
understanding the individual needs of the patient and recognising patients
as individuals who will be affected in ways that can only be predicted by a
personal evaluation and not through a generic risk approach. It was also
noted that in any case the lack of a standardised approach meant that
assessments could often be unnerving for service users who may be used to
one system and are then subjected to a different one.
Furthermore, the aversion to risk-taking or allowing patients to
take more control for fear that the professional caregiver would be held
responsible for any negative outcome was contrary to the recovery approach
that government policy upholds. The freedom to take risks would be helped
if there was more of a shift from risk factors to protective factors and from
risk assessment to needs assessment.
We took note of the NICE guidelines (National Collaborating Centre for
Mental Health, 2004):
‘Risk assessment therefore appears to be a useful means of identifying a
small group of very high risk people – that is, people who have unusually
high relative risks of further self-harm or suicide – while being too
inaccurate to be used as a screening measure to allow services to be
targeted on those whose risk is above a certain threshold.
An alternative approach is to accept that risk lies on a continuum. Risk

assessment serves to place an individual on that continuum, at the time
of the assessment. Its main value is to influence the decision about
urgency and intensity of intervention, rather than to determine the
contents of (or even the offer of) intervention.
Additionally, it can serve as a focus for discussing the person’s

current attitude to their problems, and since risk may change it can
be monitored to inform changes in the intensity of intervention. Thus
most of the items that might appear in a risk assessment scale could

be enquired about and dealt with accordingly by a needs assessment

approach. A clear advantage in assessing risk in the context of a needs
assessment approach is that the risks identified can be used to tailor
further assessment of need, and the subsequent interventions to the
individual in their particular circumstance, taking account of their past
history.’
The guidelines also state that:

‘Integrating risk assessment into a needs assessment framework
represents a possible solution to the problems identified, although
this remains to be evaluated (National Collaborating Centre for Mental
Health, 2004: p. 158).’
The Working Group views with some concern the continued reliance
on locally developed risk assessment tools. Where risk assessment tools are
used they should be seen as part of routine psychosocial assessment, not a
separate exercise.
Recommendation
•• Locally developed risk assessment tools should be abandoned. All risk assessment tools should
be evidence based. Where risk assessment tools are used they should be seen as part of routine
psychosocial assessment, not as a separate exercise.
Psychosocial needs assessment

The NICE guidance states:
‘All people who have self-harmed should be offered an assessment of
needs, which should be comprehensive and include evaluation of the
social, psychological and motivational factors specific to the act of self-
harm, current suicidal intent and hopelessness, as well as a full mental
health and social needs assessment.’ (National Collaborating Centre for
Mental Health, 2004)
However, there is evidence that this is not in place (Hughes & Kosky,
2007), particularly for those who have cut themselves and who drank alcohol
before or during the episode (Horrocks et al, 2002).The introduction of a
self-harm pathway and protocol can substantially increase the proportion
of psychosocial assessments requested and completed (Horrocks & House,
2002). Recent research found that a substantial proportion of patients
who harmed themselves were discharged from A&E departments without
a psychiatric assessment and that they may be at greater risk of further
self-harm and suicide than those who are assessed. The authors concluded
that hospital services need to be organised so that these patients receive a
psychosocial assessment (Hickey et al, 2001). There is some controversy as
to the usefulness of this form of assessment for those who have attempted
self-poisoning (Owens, 2006).
Between 40 and 50% of all participants in the College Members’ survey
reported personally undertaking psychosocial assessments with all patients
who had self-harmed; 64–71% reported that the teams in which they
worked undertook these assessments with all patients. Unsurprisingly, those
reporting liaison as a specialty were more likely to undertake assessments of
all types with all patients reporting self-harm (between 78 and 82%).5
Compliance with the NICE guidelines in relation to psychosocial

assessment was examined also in a large study of over 10 000 episodes of
self-harm at six hospitals in three cities – Leeds, Manchester and Oxford –
the authors concluding that the guidelines were far from being followed. A
person was more likely to have an assessment if they were admitted to the
general hospital, and admission practices varied between centres (Hawton
et al, 2007b).
The NICE guidelines underline the importance of a full psychosocial
assessment.
Health services aim to minimise harm and therefore try to reduce or
prevent self-harm as a priority. Many healthcare professionals view self-
harm as attempted suicide, and few healthcare professionals consider or
discuss the meaning, function or intention of acts of self-harm, instead
assuming that suicide was intended and should be prevented as far as
possible.’ (National Collaborating Centre for Mental Health, 2004: p. 73)
Although the majority of those responding to the survey reported that

either they or a member of the team routinely undertook an assessment,
some questioned the quality of this work owing to pressures mentioned
above, with a lack of time and inadequate funding.
‘Assessment is often superficial and dismissive. The act of self-harm
tends to limit the evaluation of underlying longer-term issues, whether
or not there is a diagnosable mental illness. However, the diagnosis of
depressive illness is too often assumed to be a sufficient explanation for
self-harming behaviour and suicidal ideation. Expressed suicidal ideation,
or self-harming behaviour, can lead to unthinking referral to crisis
resolution teams, rather than an attempt to understand and contain
what is happening within an existing therapeutic relationship.
The single most useful factor that might prevent these problems
is a comprehensive psychiatric assessment, including psychosocial
assessment and psychodynamic formulation. This does not necessarily
have to be done by a psychiatrist, but every psychiatrist should know
how to carry out such assessments, and as self-harm assessments are
increasingly carried out by mental health workers from other professional
backgrounds, psychiatrists have less and less opportunity to acquire and
maintain such skills.’
In addition to the patient’s psychological and social needs, it is

important that their physical needs are also properly assessed. These
are people who have tried to harm themselves physically, through
ingesting toxic substances or damaging their bodies. One has a sense that
sometimes if the psychosocial is addressed, this physical component is
forgotten despite it also being a central feature. It is one of the reasons
why psychiatrists should fulfil a key role – they are as individuals fully
medically and psychosocially trained and able to carry out a biopsychosocial
assessment.
5. Participants reporting rehabilitation, addictions and psychotherapy as their main specialty were
least likely to undertake assessments with all patients who had self-harmed. Conversely, those still
in training were more likely to undertake assessments of all types with all such patients (between
55 and 75%). Overall, 40–43% of all participants indicated undertaking psychosocial assessments
with specific patients.

Case study 14.1

The Bradford and Airedale Teaching Primary Care Trust have piloted a novel service for
patients who self-harm in which specially trained district nurses, practice nurses and nurse
practitioners provide medical treatment in the local GP surgery or from a local crisis team
out-of-ofﬁce hours (Nursing Standard, 2006). The service provides physical treatments
such as wound or burns management, but the aim is also to provide private and more
lengthy assessments in which staff are able to understand the meaning behind the act
of self-harm. Delivered in a setting outside A&E the scheme is expected to improve the
quality of psychosocial assessment and of patients’ experiences, and full implementation
depends on the response of service users. Clearly, this represents an example of efforts
to match NICE guidelines over standards of psychosocial assessments (see Training on
psychosocial assessments, National Collaborating Centre for Mental Health, 2004: p. 64),
using a process of trial and evaluation.
Recommendations
•• People attending hospital after an episode of self-harm should all receive a biopsychosocial
assessment done in accordance with the NICE guidelines by a clinician with adequate skill and
experience.
•• Psychiatrists assessing people who have harmed themselves should undertake a comprehensive
psychiatric history and mental state examination of which the assessment of risk is an important
part. Assessments of risk and need should be more closely tethered.
Changes in the culture of care

Investment in training together with better support and supervision for staff,
with input from senior clinical staff, including liaison psychiatrists, should
bring about a cultural change to benefit patients who self-harm.
Reflective practice
The College Psychotherapy Faculty put more fundamental points to us
about the need for a change in the culture of services that would also be
likely to yield better quality outcomes overall. There is, in their view, a
cultural problem of making space for thinking in many organisations, with a
performance management approach adopted in critical incident reviews that
inhibits learning from clinical experience after a suicide or other untoward
incident relating to self-harm.
‘We recommend regular reflective therapeutic space in teams to review
the self-harming behaviour. The aim of the routine reflective space
would be to learn about the emotional and psychological aspects of self-
harm and suicidal patients so that professionals would become more
able to use psychotherapeutic understanding in assessment and risk
management. A key development in the routine introduction of reflective
practice would be to improve staff morale throughout their increasing
capacity to take safely informed risks as a component of therapeutic
management which is containing in the psychotherapeutic sense of the
word.’
Reflective practice applies equally to organisations. Some psychiatrists

still perceive a blame culture in which individuals are scape-goated for
the failings of systems. Organisations may unintentionally contribute
to this, and therefore fail to learn systemic lessons. The blame culture
creates defensive practice that ill serves patient need. The practice of
reflective thinking about self-harm and suicide is especially needed across
the organisation in relation to the pressures exerted by patients whose
vulnerability collides with the vulnerability of staff and when the latter feel
they lack senior organisational support for taking risky decisions, which
could leave them exposed.
Reflective practice was also cited as a vehicle for education, team
development and to aid organisational integration. The survey repeatedly
raised important themes surrounding these issues. Reflective practice groups
can help to address service limitations already raised by the College Members’
survey and can be a vehicle to bring members of the multidisciplinary team
together, including senior and junior medical staff, link different parts of the
organisation and reduce discontinuity of care and duplication.
Recovery-orientated practice
The value of recovery-orientated practice in giving hope is central to helping
to deal with the complex situations that the service user needs to negotiate
in order then to address self-harming behaviour.
Dr Fiona Mason, a senior psychiatrist who leads a service for female
patients in a medium secure unit, gave evidence of her practice, underlining
the role that instilling hope had for the recovery of her patients.
‘Many patients never seem to have been told that recovery is an option.
Distress is increased, and effectiveness of treatment curtailed, when
individuals’ views are not taken into account; they may not have been
invited to attend their care meetings and may not have had their needs
listened to.
Service user experience, the expectation of safety, the prioritisation

of needs and beginning with the end in mind are all positive factors
in treatment for those who have self-harmed. Trust between the
service user and staff is essential. Once this is achieved then real
change can begin. Trust is built through validation of an individual’s
distress while pushing for change – making the service user feel
valued and taking into account their experiences of treatment
and desire for more effective treatment. There has to be a belief
in change, hope for the service user, who can then work towards
helping themselves.’
Discharge, onward referral and continuity of care

A central purpose of psychosocial assessment is to identify a patient’s needs
and risks and to devise a management plan to address them. Here, we
consider some issues arising immediately after an assessment and initial
treatment before then looking more generally at the care pathway.
Over a third of respondents to the College Members’ survey stated that
discharge decisions about patients were being made by junior staff with little
training or experience.6 They deprecated the fact that there was overriding
6. Sixty per cent of those reporting that rehabilitation was their main psychiatric specialty agreed
or strongly agreed with this statement, as did about 43% of those from forensic, psychotherapy,
liaison, and addictions settings.

pressure on front-line professionals to discharge individuals quickly from A&E

or in-patient care, often giving little time for the individual or professional
to take stock of the situation and provide appropriate care. A common
experience for the patient was a limited (out-of-hours) assessment and no
time to begin to recover from the physical and psychological effects of their
self-harm before they are discharged.
‘Often pressure is put upon psychiatric juniors/liaison teams to see and
discharge patients quickly rather than giving the patient the respect of
giving them some time (where appropriate) to be psychologically ready
to discuss their reasons for self-harm.’ (Respondent to College survey)
Some respondents reported that hospital admission was a problem

because of a lack of beds. Research also demonstrates that in some services
all patients referred to the general hospital following self-harm are admitted
to a medical bed, and thus are kept in hospital to allow referral to the mental
health team. In other hospitals, patients are not admitted and may be
discharged before the metal health team can assess them.
‘I always have concerns that those individuals seen in A&E and sent
home are often assessed by the most junior staff. Often there are
protocols that all admissions must be discussed with senior staff, but
perhaps those at highest risk are those being sent home and should be
discussed with senior staff.’
A significant issue raised was the importance of admitting children and

young people under 16 years of age to the paediatric ward after self-harm.
Respondents wrote:
‘It gives a very powerful window of opportunity to assess the situation
in the cold light of day and away from home circumstances.’
‘It reduces the pressure on junior staff to make decisions in the night.’
However, with limited resources the threshold for admission of young

people will be higher, with the consequence that they will have a limited out-
of-hours assessment and little or no time to recover from the physical and
psychological ill effects of their self-harm. Participants also observed that
admission of those aged over 16 years required consideration because of the
different policies on adult wards. Adult psychiatrists have a different system
by which those who self-harm are assessed immediately and discharged
without an overnight stay.
Self-discharges
People who have self-harmed are particularly likely to self discharge or
abscond (Barr et al, 2004). The problems and pressures in A&E departments
can impact on the number of people who self-discharge prematurely and who
are in a vulnerable state. As one respondent to the College Members’ survey
put it:
‘... the group of deliberate self-harm individuals who can get missed is that
of the self-discharges from the emergency department – in our centre we
have developed a weekly review of such missed cases, and action is then
taken to follow them up or alert their GP or others involved in their care.’
Patients who self-harm and who leave the acute hospital environment
before an assessment takes place have an increased risk of subsequent self-
harm (Crowder et al, 2004).
In its evidence to the Working Group Committee, the charity SANE

gave two examples (Case studies 14.2 and 14.3).
Case study 14.2

A man diagnosed with schizophrenia who had absconded from a psychiatric hospital earlier
in the day was found trying to jump off Tower Bridge. He was taken to an A&E department
and left without constant supervision to wait for an assessment. Sadly, the wait, it
appeared, was too long. Unnoticed, he left the hospital, then jumped off Westminster
Bridge into the Thames and drowned. SANE would like to see a speedier response in A&E
departments, and specialist input from psychiatric teams, to people who have attempted
suicide or may be at risk of taking their lives.
Case study 14.3

A talented artist in his forties who had had schizophrenia and bipolar disorder since the age
of 17 had learned, when suffering his frequent relapses when he would become suicidal,
to admit himself to a particular hospital where he could find the space, nursing care and
protection he knew he needed. When the hospital was demolished, the only bed available
was on the third floor of a unit on a main road, where there was no space or activities,
which he found oppressive. Nevertheless, it was the only place where he could feel safe.
When his wife begged for him to be admitted to the unit just before Christmas, he was told
that he would be visited instead by a community team and a psychiatrist left a message
on his phone offering him an appointment a month ahead. No one responded to his and
his wife’s repeated messages about how desperate he was becoming. He hanged himself.
Referral to general practitioners

There needs to be effective communication between GPs and secondary care
for people who have harmed themselves and need further attention. The NICE
guidelines recommend that the information following a psychosocial assess
ment should be passed on to the patient’s GP. Mental capacity and evidence
of mental illness should be communicated to GPs if patients leave before a
specialist assessment. College guidance recommends that for people admitted
to medical wards, information should also be passed to GPs (as well as a
referral to a specialist) within 3 days (Royal College of Psychiatrists, 2004). In
one study (Cooper et al, 2008b), of the 93 cases seen in the A&E department
at a teaching hospital over a month, only 62% of cases were referred.
Clinicians in A&E provided few communications, and they were of limited
content. Communication from psychiatric staff was the most detailed. The
authors conclude that reliance on communication by A&E staff would leave
a substantial proportion of patients discharged from A&E with no or minimal
communication to primary care. Psychiatric services also need to improve the
rate of communication to the patient’s GP following assessment.
More than 6% of patients discharged from psychiatric in-patient
care are readmitted for an episode of self-harm within 12 months, with a
third of these episodes occurring in the month after discharge. Self-harm
after discharge from hospital shares many of the features of suicide after
discharge. Gunnell et al (2008) conclude that interventions should be
developed to reduce risk during this period.

Marjorie Wallace from SANE expressed her view to the Working

Group:
‘... the first 48 hours after discharge are when people are at their most
vulnerable. Many are simply left to get home alone and are then not
seen or contacted by a team until up to 7 days later. The transfer from
a safe, secure and monitored environment back into society can be very
traumatic for people, and there needs to be a greater recognition of the
added stress this brings. SANE has offered to work with psychiatric teams
via its telephone helpline service, to call service users when they have
got back home after discharge and then again at regular intervals, at
times such as evenings and weekends when other help might be difficult
to reach, alerting them to potential crisis. However, monies were not
forthcoming from primary care trusts to fund this preventative service.’
Care pathways
The management plan lays the foundation for future long-term care, which
in the case of self-harm requires long-term thinking and often involves
multiple partners. Management plans should embrace a long-term strategic
perspective and not merely respond to the immediate concerns.
The longer-term management of self-harm appears to vary in quality.
Of great concern is the fragmentation of services, duplication of assessments
and people being lost to the system. Lack of follow through also arises
because of communication between different teams and staffing shortages,
especially over the summer.
More than half of all respondents (55%) to the College Members’
survey consider that services are available outside the immediate crisis.
However in relation to the ability to provide short-term follow-up there was
a difference between the main psychiatric specialties and those working in
liaison, who reported that performance was neither good nor very good in
a third of all cases. There was a particular problem with limited follow-up
services for 16- to 18-year-olds.
‘In CAMHS we do not have an outreach crisis service, which makes
follow-up of non-attenders very hard. Child and adolescent mental
health services are underresourced to cover recurrent individuals with
self-harming behaviour. Also when patients present from a non-local
area to our area we cannot be sure of the kind of follow-up they get.’
Another group of patients for whom long-term care is essential but

often lacking are the patients whose self-harming behaviour is entrenched
and repetitive. Some have a diagnosed personality disorder. In commenting
on the lack of services for these ‘most stigmatised patients’, one respondent
to the survey stated:
‘Some of them need to be seen as long-term patients, with proper
management and treatment plans, something that goes against the
current climate of cutting the provisions and the recovery model. They
might recover from a particular episode of self-harm, but unless they are
taken on seriously and treated, another crisis is just around the corner,
draining the resources in a continuous manner.’
Less than a half of respondents (48%) reported that a self-harm care

pathway or policy existed or was being developed; almost a quarter (23%)
reported that no pathway document existed; and 29% did not know. It
appears that pathways are best developed in child and adolescent settings.
Pathways are least well developed for those attending addiction services.
This is most concerning. We trust that these defects will be fully considered
by NICE and should be taken up by the College in future work on assessment
of people who harm themselves.
There were several examples of positive experiences. One psychiatrist
noted:
‘I have found that focusing training on well-motivated teams of people
with strong links to the voluntary sector, crisis teams, and an ability
to communicate quickly and effectively with primary care, available to
say A&E departments and related general hospital units, is an effective
way to raise standards, and reduce bad practice and stigma. They
can educate general hospital colleagues. Such teams should have a
psychiatrist providing leadership and support around audit, research and
clinical decision-making over prescribing, etc.’
In the view of one participant commenting on A&E, a multi-agency

pathway should replace the existing model:
‘… of a line of professionals carrying out their individual assessments
without a care planning meeting or even having a robust mechanism to
liaise with each other to ensure safe management/discharge.’
The College Faculty of General and Community Psychiatrists said that

the process and practice of the care programme approach (CPA) needed
to be strengthened for patients under secondary mental healthcare. The
National Suicide Prevention Strategy for England (Department of Health,
2002a) as well as confidential inquiries into the causes of suicide and
undetermined deaths have frequently relied on appropriate implementation
of CPA policies for patients admitted to the psychiatric hospitals, as well
as for patients being managed by CMHT as an important standard of safe
practice.
‘Even where good liaison psychiatry services exist there still appears to
be a barrier integrating with A&E. Having separate general and mental
health trusts exacerbates the problem. I would like to see the mental
health staff actually based (not visiting from separate building or office)
alongside A&E staff. At present there remains a culture of “mental
health” problem, we’ll do our bit, stitch them up/parvolex, then refer
them to mental health, nothing more to do with us. Mental health staff
come as outsiders, often completing two sets of records. This is OK, but
the separation of mind and body is completely outdated and I would like
to see true holistic practice.”
Different models of service delivery for mental health patients are

being discussed and practiced (Royal College of Psyciatrists, 2010), driven
by the economic downturn and a shortage of financial and staff resources.
This is also an opportunity to do things better and maybe get back to
the basics of good patient care. We note these developments, which will
impact on people who self-harm and should be used to improve care
pathways, reduce duplication and lead to better collaboration between
services.
It is beyond the scope of this report to consider these issues in detail,
given also more in-depth work that can be achieved by NICE. However, the
top-line messages are clear – the need for an agreed multi-agency pathway
that provides for long-term care that is clinically appropriate and fosters a
therapeutic alliance with person and clinician. Plans of treatment and care

need to embrace a long-term, strategic perspective and not merely respond

to immediate concerns.
In the light of new developments in service delivery and of these
problems it would be timely for the College to review and update its existing
guidance on a pathway for self-harm.
Recommendation
•• The College Report Assessment Following Self-harm in Adults (2004) should be updated, reflecting
findings in this Report, relevant NICE guidelines and other policy and practice-based developments,
including the results of service redesign initiatives.
The range of interventions for self-harm is discussed elsewhere. Many
respondents to the survey commented on the need for training in these
therapies and for further research to be funded so that they may improve the
evidence base. It was noted that self-harm is considered to be challenging
to manage owing to limited understanding and therefore avoidance
by professionals, thus becoming an exclusion for such individuals who
need the most help. Proper training is needed to improve the skills of all
professionals.
‘... making sure that staff using psychological therapies in this area are
properly trained and not just deployed having had ‘taster’ experiences
in various therapies, as I think this could be very harmful to patients
particularly in the long term.’
The answers to the survey questions on the availability of psychological

therapies were revealing. In liaison, general adult, addictions, and learning
disabilities about 50–55% of respondents agreed that such therapies
were widely available in their organisation for people who self-harmed.
This contrasts with 73–78% of those respondents practicing in child and
adolescent, psychotherapy and forensic settings.
The impact of the improving access to psychological therapies (IAPT)
programme on other therapy services was regretted, but it was also noted
that in Scotland, where there is no IAPT programme, the lack of services is
greater.
‘Still there are people who find it difficult to access psychological input.
I would recommend all people who present with self-harm irrespective
of comorbid mental illness or not should have mandatory psychological
input, as most of the patients use self-harm as a maladaptive coping
strategy and it should start from the first attempt of self-harm –
doesn’t matter if the self-harm was significant or not. We should
not wait for multiple self-harm episodes to justify the psychological
input.’
‘Locally, the lack of psychological interventions for young people who

self-harm is a matter of significant concern. We are fairly confident
that we assess adequately but are often not able to offer appropriate
intervention owing to lack of resources, having poor accommodation and
a severe lack of psychologists or other specialists who might provide
these.’
There is a duty on services to provide those interventions for self-harm

that are recommended by NICE.
Recommendation
•• Mental health commissioners take more account of the needs of people who harm themselves and
ensure that evidence based psychological therapies are available for individuals who need them.
Research needs to be funded into relevant therapies to improve the evidence base.
Dedicated self-harm services
General views
Respondents to the College Members’ survey were divided as to the role of
dedicated self-harm services. The advantage of specific self-harm services
is that members of staff can help train their colleagues more effectively;
however, it does mean some fragmentation of services. It was also said
that in most cases a holistic approach that treats self-harming behaviour
as one part of the person will be most effective. For these reasons we do
not take a position on a separate stand-alone self-harm service as the
preferred structure for delivering care, given that there is such individual
variation between patients presenting with it. A well-resourced (especially
for psychotherapies) and trained CMHT and primary care service may well
provide a more joined-up and coordinated service than a separate one.
However, even though dedicated self-harm services were not seen
as necessarily a model for widespread adoption, there were some good
examples dealing with the most severe, entrenched and repeated cases of
self-harm (see below). One respondent wrote:
‘I run one of the few specialist psychiatric treatment and training
services for people who repeatedly self-harm. We are based in South
London. We have excellent clinical results (backed up by robust outcome
data) and yet perpetually struggle to obtain primary care trust funding
for referred patients and are in a constant battle over funding.’
Repeated self-harm
People who repeatedly self-harm over a long period of time are a distinct
group who are at a particularly high risk of suicide (Hawton et al, 2003).
Negative feelings associated with treating these people was cited as a major
cause of poor service provision. Staff reported that they felt frustrated
and had a sense of failure in regard to individuals who repeatedly harm
themselves because they feel unable to understand or treat the causes
of self-harm (National Collaborating Centre for Mental Health, 2004).
Individuals who repeatedly self-harm were said to be considered a drain on
acute services, absorbing much clinical time, often exhibiting challenging
behaviour, and there was too little training on how to manage their behaviour
and too few therapies to care for their needs.
The Royal College of Psychiatrists (2006) surveyed professionals
working in general hospitals and came to the same conclusions. There need
to be improved services for people who repeatedly harm themselves. Many
of these people have long-standing personality-related and multiple life

problems, may be misusing drugs or alcohol, and those with a diagnosed

personality disorder are also highly represented. One respondent opined:
‘There is much that can be done to assist them but there is no
investment or money available to create a specialist service... If an age-
inclusive service could be developed with the aim of early education and
support could be developed (i.e. like the early intervention service), then
the significant costs to the service overall would be reduced.’
Another respondent stated that continued investment in specialist

services for people with personality disorder that offer evidence-based
treatments could play an important part in reducing the incidence of repeated
self-harm.
‘There needs to be comprehensive and “systemic” training of adult in-
patient ward staff in the management of the person who repeatedly
self-harms ... complemented by more availability of psychology/
psychotherapy support or, arguably, more consultant “time” available on
the wards to oversee/supervise staff in the management of these more
challenging cases.’
Evidence was received from a dedicated self-harm service in England

(Case study 14.4).
Case study 14.4

There are about 1300 presentations to the Emergency Department of the Manchester
Royal Infirmary each year with a repetition rate of 27% over 2 years. The median time
to repetition is 12 weeks but 10% of repeaters do so within the first week of the index
episode. Overall, 60–90% of people have some form of major psychosocial problem –
depressive disorders, anxiety states, alcohol or substance misuse and related problems,
abusive relationships, complex family difficulties or other difficult social circumstances.
About 50% of patients are found to be illiterate or to have very low levels of literacy (15%
illiterate and most have an average reading age of 7–8 years) and the level of social
deprivation is high.
The specialist team (Self-Harm, Assessment, Follow-up and Engagement, SAFE) run weekly
sessions in GP surgeries in self-harm hot spots and also see people at home. There is a
low level of support and care from patients’ families, who are often not in a mental state
to provide it.
There are three nurse therapists who assess and treat self-harm. The SAFE team provides
a specific treatment service for people who self-harm, with four sessions of psychodynamic
interpersonal therapy. They link up with other services if necessary and work closely with
GPs. An integrated continuous training system is headed by a liaison psychiatrist. Ease of
access is the key to ensuring that people remain in treatment. Rather than forcing them
to come to a hospital, which they may find difficult, services are offered at a GP’s surgery
or at home, with a higher uptake rate than with hospital appointments. These home visits
or treatments in local general practice is more effective.
Recommendation
•• That there is more research into different models of care for people who repeatedly self-harm with
the effectiveness of dedicated self-harm services as part of such an enquiry. We trust that this will
be considered as part of the work on the forthcoming NICE Guideline on Self-harm.
Issues for some particular groups

Three groups of service users were particularly singled out for mention by
respondents to the Working Group survey: people with personality disorder,
older people, and prisoners and forensic patients. Some of the issues have
been considered earlier but here we mention some particular points.
People with diagnosed personality disorder

People with a diagnosed personality disorder are traditionally a stigmatised
group. They are highly represented among prisoners and among those who
repeatedly self-harm. Attitudes to and service provision for people with
personality disorder was seen as particularly poor. Mainstream services are
sometimes reluctant to take them on partly because they absorb much time
and resources. Some psychiatrists do not see personality disorder as part of
their remit and are uncomfortable treating them or simply untrained to do
so. The problems were summarised by one respondent.
‘These are the most stigmatised group among our patients, seen as
particularly demanding of services and emotionally draining. Their care
is often from crisis to crisis, with very little understanding except from
psychological services, where I work.
I would like to see clarity regarding the role of the Mental Health
Act in psychiatrically managing personality disordered patients who
repeatedly self-harm (i.e. as a preventive intervention). At times it
appears services may make the personality disorder worse by detaining
patients in a countertherapeutic manner, solely to reduce the risk of
suicide.’
Older people
Older people have been seriously disadvantaged by the current organisation
of mental health services. They have been unable to access crisis resolution,
assertive outreach, home treatment and early intervention teams in England.
The Audit Scotland report found a similar trend in Scotland, with older people
having difficulties accessing care. There are only 0.6 health psychologists per
100 000 people for the over 65s in Scotland, whereas for 20- to 64-year-olds
the ratio is 6.7 to 100 000 (Audit Scotland, 2009).
Liaison psychiatry services covering general hospitals and A&E
departments are also lacking. At the same time the limited number of
specialist services has been unable to manage the growing body of people
who need care. Older people have substantially less access to psychological
therapies than younger adults, although the IAPT programme in England
applies equally to older people.
This overall discrimination, which is now acknowledged by
governments, has had an impact on those who self-harm. The number of
people over the age of 74 with depression is projected to increase by 80%
by 2026 (McCrone et al, 2008). Therefore, there is likely to be a significant
increase in the number of older people presenting with self-harm and suicidal
behaviour, and in the number of those who complete suicide.
‘It may be no coincidence that only one in six older people with
depression receive treatment of any sort and while 50% of younger

people with depression are referred to specialist services it is only 6%

of older people.’ (Lee, 2007)
General adult psychiatrists lack the specialist skills to treat these

patients, indicating that specialist old age psychiatrists’ services are called
for.
‘Psychiatrists for adults of working age often seem out of their depth
when dealing with deliberate self-harm patients who have multiple
physical pathologies and take multiple medications and who already
have a poor prognosis because of physical illness.’
‘Self-harm in the elderly is sometimes assessed by crisis teams that

mainly work with working-age adults. They lack skills in assessing older
adults. Specialised crisis teams/liaison psychiatry teams are needed for
the elderly.’
It was stated that there is little or no provision of self-harm care

pathways for older adults. Developing pathways with adult services was in
its infancy and guidance particularly related to older people was lacking and
should be developed.
‘Whether through lack of training, confidence, etc., the [adult] staff
teams often feel deskilled with older people and tend to admit where
a younger person may have access to specialist day services or crisis
team.’
The Chief Executive of the National Benevolent Fund for the Elderly,
Julia Robertson, pointedly characterised the importance of isolation as
follows:
‘Nearly 600 000 older people leave their house only once a week or even
less.
In the UK, 300 000 older people often go an entire month without

speaking to friends or family.
An estimated 200 000 older people in the UK do not receive the help they
need to leave their house or flat.
A third of UK suicides committed by over-55-year-olds.’
The College Faculty of Old Age Psychiatry told the Working Group that:
health services need to recognise that they should actively treat depression
in later life; have a low threshold for referral to specialist services for older
people; end the discrimination in their access to services in general; and not
to underestimate the seriousness of self-harm and suicidal behaviour in later
life. The Working Group strongly endorses their views.
Prisoners and forensic patients

The Corston Report explicitly raises concern about the risk of self-harm in
prisons for women.
‘It is clear to me that prison cannot be the right place for managing
these types of behaviours [self-harm], which stem from deep-rooted
long-term complex life experiences such as violent and/or sexual abuse,
lack of care and/or post-traumatic stress disorder, in addition to a
personality disorder. These are problems created within the community,
which is where they should be addressed. The Prison Service cannot and
should not be expected to solve social problems. Low-level offending

women who self-harm should be diverted out of the route to prison into
appropriate NHS services.’ (Corston, 2008: p. 76)
Baroness Corston also expressed concern at the gaps in training prison

officers to work with people who present a high risk of self-harm.
‘Equally shocking is … the expectation that prison staff will take on the
management of these women, insufficiently trained and sometimes
uncomprehending of the motivation that drives women to injure
themselves, as part of their normal daily (and nightly) routine.’
(Corstom, 2008: p. 12)
As reported in Part I, recent initiatives have brought improvements

in England. A new strategy for England, Improving Health, Supporting
Justice (Department of Health, 2009b), takes account of both the Corston
Report and Lord Bradley’s review of people with mental health problems and
intellectual disabilities in the criminal justice system (Bradley, 2009).
Respondents to the College survey gave examples of where a multi-
agency response to the risk of self-inflicted death in prison works well (Case
study 14.5)
Case study 14.5

A consultant psychiatrist who works with the Mental Health In-Reach Team at HMP Leeds
and HMP Wealstun offers rapid psychiatric assessment and treatment of inmates with
severe mental health problems and offers consultation with primary care and secondary
care services within the prison. This will include inmates with thoughts and acts of self-
harm, which enables healthcare and the prison to manage these persons effectively as well
as to be able to identify early any treatable mental illness.
Some of the people with the most severe mental illness are located
in secure hospitals. A successful programme for women who have been
transferred from prison to hospital was outlined to the Working Group (Case
study 14.6).
Case study 14.6

St Andrews is a medium secure service for women, most of whom have personality disorder
as a primary or secondary diagnosis, have highly disrupted backgrounds, a high level of
previous substance misuse and almost all of whom self-harm (93%). A graded phased
multidisciplinary treatment plan is devised and implemented over time. The programme is
based firmly on recovery principles and aims to enable women to take control of their lives,
to find alternative coping mechanisms to self-harm and to consider their future in a more
positive way. The programme contains a range of therapies and some use of clozapine has
proved beneficial.
However, respondents to the College Members’ survey also cited the

lack of equivalent standards of care for prisoners, including psychological
therapies, the need for joint working of prison and NHS staff and the urgent
need for training of prison staff in self-harm. These issues apply in all parts
of the UK.
‘Self-harm in prison has a huge association with untoward childhood
experiences, particularly sexual abuse, and is associated with the general

mental health consequences of such abuse. The women would often

benefit from CBT directed at the experience itself, and at depression,
anxiety and PTSD. Sometimes they get it. In my view, the College have
a duty in this review to reserve a special place for prisoners.’
Prisoners and those in forensic facilities are particularly vulnerable to

self-harm and suicide. We welcome the work that is being taken forward to
improve their situation in England.
Recommendations
We recommend that the following four approaches be energetically pursued in future work throughout
all the countries of the UK.
•• Diversion from the criminal justice system for those with mental illness.
•• Equivalent care for prisoners as for those in the general population.
•• Timely and speedy prison transfer for those with severe mental illness.
•• Effective training for prison staff.
15. Third-sector providers
The important role of the third sector in dealing with the problems of self-
harm was emphasised by individual College Members. It is already clear from
the College Members’ survey that psychiatrists frequently refer patients to
voluntary services. A total of 81% respondents stated that they refer to their
mental health services ‘often’ or ‘sometimes’ and 82% to their other services,
but the nature of these referrals has not been established.
We also heard from the Samaritans that they are seeking to establish
protocols with statutory services and have some service agreements with a
range of statutory health providers, including GP practices, A&E departments
and Social Services. They said that they are sometimes hampered by barriers
to a closer relationship. Some professionals are reluctant to make referrals
to them because of their uncertainty as to the medico-legal transfer of duty
of care and different attitudes to risk. There is no particular General Medical
Council policy that prevents referrals, but a psychiatrist must in all cases
ensure that the person or organisation to whom the referral is made has the
requisite skills and attributes for the patient.
Greater dialogue and collaboration could be expected to resolve some
of these uncertainties, and we believe that this issue needs to be urgently
explored further. The Royal College of Psychiatrists should work with the
major third-sector providers to provide appropriate advice and information
on the issue of collaborative working. It is clear that psychiatrists and other
mental health professionals can learn from the experience and expertise of
third-sector providers, who can in turn be informed by collaboration with
these professionals.
Recommendation
•• The Royal College of Psychiatrists, other mental health professionals and UK Departments of Health
should acknowledge the crucial contribution of the third sector in dealing with self-harm and suicide,
explore ways of partnership working that obviate anxieties about competence and medico-legal
concerns and each should have the opportunity to learn from the experience of the other sector.

16. Conclusions
It is likely that there is much variation across the country in the standard of
care for people who harm themselves. That much practice is humane and
effective is borne out by the fact that there is a reasonable level of staff and
service user satisfaction in the results of this and other surveys.
Nevertheless there is enough evidence to demonstrate that we are far
from achieving the level of care that service users need or the standards
set out in policies and guidelines. Poor assessments, relying too much on
risk issues, staff unskilled in dealing with patients who harm themselves,
inappropriate discharge arrangements, lack of follow-up of patients, lack
of care pathways, insufficient access to psychological treatments and poor
access to services for particular groups amount to inadequate standards of
care that impact on the lives of service users and their families. There is a
serious problem relating to the deployment and availability of senior staff,
with adequate psychotherapy and psychiatry training. It is likely that because
of these services and staffing defects, the majority of self-harm remains
invisible until a crisis occurs, adding to human misery and to the stress on
hospital services.
Although some might consider that a time of economic austerity is an
inauspicious time to propose improvements in care, we believe that it also
provides opportunities to improve practice. This is a coherent set of proposals
which taken together could improve service users’ experience and care as
well as the morale and the skills of those who work with them.
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Appendix I:
Online survey of College Members*
Section 1
What was the aim of the survey?
The survey aimed to gauge the opinions and experiences of Members of the
Royal College of Psychiatrists on the issue of self-harm.
Self-harm was defined as ‘self-poisoning or self-injury, irrespective
of the purpose of the act. This includes acts with and without suicidal
intent’. This included any person for whom self-harm was a relevant clinical
concern.
What questions did it ask?

The survey was comprised of ten questions. Eight questions required at least
one quantitative response, while two asked for qualitative data.
In Section 2 of this report, we present quantitative data based on
responses from 1540 participants.
In Section 3, we present qualitative data based on responses from the
540 participants (35% of the total sample) who answered the question ‘The
College is currently undertaking a comprehensive review of policy and practice on
self-harm. This will report back later in 2009. Do you have any other issues that you
would like to see addressed by that review?’.
How was it conducted?

An invitation to participate in the survey was sent to 9750 College Members
in the UK with a working email address. This constitutes 78% of the UK
College membership (n = 12 554).
Who responded?
1540 College Members completed the survey (16% response rate).
*Carried out by the Policy Unit, Royal College of Psychiatrists, 29 June–23 July 2009. Sample size n = 1540.

P sychiatric specialty
Of the sample, 46% gave their main specialty as general adult psychiatry
(Table 1). Other groups included child and adolescent psychiatry (16%), old
age psychiatry (11%), and forensic psychiatry (5.2%). Just under 7% of all
participants were not decided/still in training (6.9%).
It is not currently possible to compare the main psychiatric specialty
reported by consultation participants with the wider profile of all UK College
Members. This is because this data is not collected in a comparable format.
R egional breakdown
Approximately 85% of all participants belonged to the English Division of the
College, followed by 9.2% within the Scottish Division, 4.2% in the Welsh
Division, and 1.8% in the Northern Ireland Division (Table 2).
In comparison to the regional profile of the total UK College
membership, there were some differences between the numbers of
participants from the South-East, South-West, London, and Northern and
Yorkshire Divisions.
Membership status
About 64% of participants were College Members, followed by pre-
membership trainees (16.8%), and Fellows (14.7%) (Table 3). In comparison
to the profile of the total UK College membership, there were some
differences between the numbers of participants who were College Fellows
and Members.
Which data are not presented in this report?

Additional quantitative tables are available at www.rcpsych.ac.uk/risktoself.
These provide quantitative data for each survey question broken down by
reported main psychiatric specialty.
Qualitative data on the type of service in which participants primarily
encountered people who had self-harmed are not presented in this report,
owing to issues with data quality and specificity.
What are the limitations of the survey?

The survey invited all UK College Members with a working email address to
participate.
The resulting responses therefore represent a non-probability sample
with a sampling bias towards members with email addresses. They are not
statistically representative of the wider College membership. The results,
however, do provide important insights into the views and opinions of a
comparatively large number of the College membership.
Section 2: Quantitative results

In this section we present quantitative data based on responses from 1540
participants.
Appendix I
Table 1 Main psychiatric specialty reported by participants (n = 1540)

Specialty n (%)
General adult 711 (46.2)
Old age 170 (11)
Psychotherapy 52 (3.4)
Academic 13 (0.8)
Liaison 52 (3.4)
Child and adolescent 246 (16.0)
Learning disability 52 (3.4)
Forensic 80 (5.2)
Addiction 33 (2.1)
Rehabilitation 25 (1.6)
Not decided /still training 106 (6.9)
It is not possible to accurately determine the main psychiatric specialty of all individuals registered
as Members with the College. Members can register with one or more of the ten different Faculties
within the College, but the ability to register with multiple Faculties does not make for a meaningful
comparison.
Table 2 Geographic division of participants

Division All participants, n (%) Total UK College membership,a n (%)
England (total) 1302 (84.5) 10 456 (83.6)
Eastern 110 (7.1) 875 (7.0)
South East 140 (9.1) 1533 (12.3)
South West 128 (8.3) 890 (7.1)
London 335 (21.8) 2886 (9.6)
Northern and Yorkshire 191 (12.4) 1202 (9.6)
Trent 114 (7.4) 901 (7.2)
West Midlands 135 (8.8) 956 (7.6)
North West 149 (9.7) 1213 (9.7)
Scottish 141 (9.2) 1199 (9.6)
Welsh 65 (4.2) 507 (4.1)
Northern Ireland 27 (1.8) 342 (2.7)
a. Total UK membership is based on the number of individuals registering at a College Division as of 31 January 2010.
Table 3 Membership status of participants

All participants, n (%) Total UK College membership,a n (%)
Fellow 226 (14.7) 2053 (16.4)
Member 562 (63.5) 7803 (62.2.)
Affiliate 56 (3.6) 515 (4.1)
Pre-membership Psychiatric 258 (16.8) 1997 (15.9)
Trainee
Honorary Fellow 2 (0.1) 65 (0.5)
Specialist Associate 16 (1) 104 (0.8)
Other 11 (0.7) 17 (0.1)
a. Total UK membership is based on the number of individuals registering at a College Division as of 31 January 2010.

Which type of assessments are undertaken by psychiatrists?

Between 40 and 50% of all participants reported personally undertaking
psychosocial, risk or mental state assessments with all patients who self-
harmed (Table 4).
A total of 40–43% of all participants indicated undertaking risk, mental
state or psychosocial assessments with specific patients.
Approximately 10% of all participants indicated undertaking such
assessments with specific patient groups (10%).
Between 1 and 7% didn’t undertake any form of risk or psychosocial
assessment. This may be because such work was undertaken by other
members of the mental health team in which they worked.
Table 4 (www.rcpsych.ac.uk/risktoself) provides data on assessments
personally undertaken by psychiatrists broken down by self-reported
psychiatric specialty. It indicates that participants reporting rehabilitation,
addictions, and psychotherapy as their main specialty were least likely
to undertake mental state or risk assessments with all patients who self-
harmed.
Conversely, those still in training are more likely to undertake
assessments of all types with all patients reporting self-harm (between 55
and 75%).
Which type of assessments are undertaken by teams?

A larger proportion of respondents reported that the teams in which they
worked undertook risk or psychosocial assessments with all patients who had
self-harmed (Table 5). This was reported by 64–71% of respondents.
Overall, 14–16% of respondents reported their teams undertook
assessments with specific patients.
Table 4 Thinking about the setting where you primarily work with people who have self-
harmed (%)
(a) Do you (b) Do you personally (c) Do you
personally undertake risk personally
undertake mental assessments undertake
state assessments psychosocial
assessments
With ALL people 48.2 48.5 39.5
who have self-
harmed
With SPECIFIED 9.5 10.4 9.8
GROUPS of people
who have self-
harmed
When necessary for 41.5 39.6 43.2
SPECIFIC PATIENTS
who have self-
harmed
I DO NOT undertake 0.7 1.5 6.7
this assessment
Don’t know 0.1 0.1 0.8
Base 1531 1522 1503
Appendix I
In total, 13–15% of respondents indicated they undertook assessments

with specific patient groups.
Only 1–3% reported that their team did not undertake any form of
assessment.
This raises questions about the circumstances in which it is appropriate
for psychiatrists to decide when to undertake a risk or psychosocial
assessment with patients who have self-harmed.
Psychiatric specialties
Table 5 (www.rcpsych.ac.uk/risktoself) provides data on assessments
undertaken by the teams in which psychiatrists work, categorised by
psychiatrists’ self-reported psychiatric specialty. The table indicates that
participants reporting learning disability and academic as their main specialty
were least likely to undertake mental state, risk or psychosocial assessments
with all patients who had self-harmed. Conversely, those reporting liaison as
a specialty were more likely to undertake assessments of all types with all
patients who had reported self-harm (between 78 and 82%).
Perceived quality of services for people who self-harm

The consultation asked participants to rate the performance of the service
settings in which they worked. This evaluation related to six aspects of
service provision to people who had self-harmed (Table 6):
item (a) – equality and parity of provision
item (b) – safe and supportive environment
item (c) – treatment for physical consequences
Table 5 Thinking about the setting where you primarily work with people who have self-
harmed (%)
(a) Does your team (b) Does your team (c) Does your
undertake mental undertake risk team undertake
state assessments? assessments? psychosocial
assessments?
With ALL people 67.2 70.6 64.3
who have self-
harmed
With SPECIFIED 13.5 12.8 14.6
GROUPS of people
who have self-
harmed
When necessary for 14.7 13.7 15.8
SPECIFIC PATIENTS
who have self-
harmed
The team DO NOT 2.8 1.1 2.3
undertake this
assessment
Don’t know 1.9 1.7 3.0
Base 1490 1488 1477

item (d) – information provision

item (e) – communication with carers
item (f) – short-term follow-up
T otal sample
Across all six items, the lowest proportion of all participants reporting that
the service performance was good or very good was 67% (item (d)), and the
highest was 82% (items (a) and (e)).
Across all six items, the proportion of all participants reporting that
service performance was poor or very poor ranged from 3.2% (item (c)) to
just over 7% (items (b) and (d)).
The working relationship with carers was rated good or very good by
82% overall, although trainees were less positive (66%).
P sychiatric specialties
Across the main psychiatric specialities, there were differences in ratings
(Table 6; www.rcpsych.ac.uk/risktoself).
Greater dissatisfaction was, on balance, voiced by those in liaison,
learning disability and old age services. Furthermore, trainees rated services
less highly compared with consultants.
Those working in child and adolescent services had the highest level
of satisfaction.
In relation to the ability to provide short-term follow-up, there was a
difference between the main psychiatric specialties reported and participants
working in liaison psychiatry, with reports that performance was neither good
nor very good in a third of all cases (33.3%).
Care pathways for self-harm

In answer to the question, ‘In the setting where you work, is there a policy
or published “care pathway” for people who self-harm?’, 40% of respondents
reported that a self-harm care pathway or policy existed.
In the overall sample, 8% indicated that although there was currently
no care pathway, one was being developed; 23% reported that no pathway
document existed; and 29% did not know.
The term ‘care pathway’ is defined as planned, coordinated and
multidisciplinary practice. This can span across different health and social
care sectors, as well as the statutory, voluntary and private sectors.
P sychiatric specialties
Differences occurred between main reported psychiatric specialty: 77% of
respondents working in child and adolescent settings indicated that there was
a pathway or that one was being developed, compared with 48% in liaison
psychiatry and 27% of those in addictions.
Referrals
In terms of referrals made to other services, approximately 40% of all
respondents answering this question indicated that they made a referral
often and sometimes to a dedicated self-harm service (Table 7).
Table 6 Continuing to think about the setting where you primarily work with people who self-harm, we’d like you to rate this setting’s
performance in relation to self-harm (%)
(a) People (b) People who (c) People who have (d) Staff (e) With (f) It is possible
who have self- have self-harmed self-harmed are provide full appropriate to offer short-
harmed are are offered an offered treatment information patient consent, term follow-up
treated with assessment for the physical about the staff effectively for people who
the same care, environment that consequences of treatment communicate and have presented
respect and is safe, supportive self-harm options to work with carers with self-harm
privacy as any and minimises any patients where this is
patient distress indicated
Very poor 0.2 0.5 1.0 0.7 0.2 1.5
performance
Poor 6.3 6.9 2.2 6.6 6.3 4.7
performance
Neither poor 10.5 17.4 13.4 19.2 10.5 10.2
nor good
Good 43.7 45.0 43.9 44.7 43.7 40.4
performance
Very good 38.4 29.3 35.2 22.3 38.4 40.2
performance
Base 1530 1528 1513 1523 1523 1517
113
Appendix I
Table 7 How frequently do you (or your team) refer people who have self-harmed to the
following services? (%)
Housing Employment Education Dedicated Voluntary Voluntary
self-harm sector: sector:
services mental other
health
service
Often 14.7 7.8 12.8 14.4 20.6 25.9
Sometimes 64.0 51.1 50.7 26.0 60.5 56.5
Never 12.9 26.2 22.1 12.5 9.7 10.5
No service 1.9 5.0 4.9 30.8 3.7 1.6
exists
Don’t know 6.5 9.8 9.4 16.3 5.5 5.5
Base 1497 1486 1472 1482 1491 1493
Table 7 How frequently do you (or your team) refer people who have self-harmed to the
following services? (%)
Primary Acute Acute Specialist Private or Other
care hospital: hospital: mental independent
general A&E health sector
ward services
Often 37.9 12.2 23.4 28.1 2.1 7.4

Sometimes 50.7 66.4 68.4 59.8 30.5 11.3
Never 8.3 17.3 5.6 7.4 52.3 22.6
No service exists 0.9 0.5 0.4 1.5 3.5 3.9
Don’t know 2.2 3.6 2.3 3.2 11.5 54.8
Base 1479 1488 1482 1483 1474 557
Continued
Thirty per cent of respondents, however, indicated that no dedicated

self-harm service’ existed that they could refer to. In relation to housing,
79% of respondents often or sometimes made referrals to such services.
This was particularly the case among those working in addictions (100%).
Across the sample, there were lower rates of referral to work or to
education.
Breakdowns by main reported psychiatric specialty are contained in
Table 7 (www.rcpsych.ac.uk/risktoself).
NICE guidelines
Seventy-four per cent of respondents reported having read the NICE
guidelines on self-harm; 24% had not read the Guidelines and 1.9% did not
know.
The proportion of respondents reading the NICE guidelines on self-
harm were lowest in those working in addictions (50%), and highest in
those in child and adolescent settings (86.6%) (Table 7; www.rcpsych.ac.uk/
risktoself).
Appendix I
Training
Forty-six per cent of the total sample replied that they had received specific
training in relation to repeated self-harm.
Thirty-six per cent of those reporting old age as their main psychiatric
specialty, 42% of those from addictions and 43% of those in general
and adult settings reported that they had had this training. The highest
percentage of those who have been trained were in liaison settings
(62.7%)
Attitudinal questions
T raining : psychosocial assessments
Table 8 required participants to state their level of agreement with a range of
statements. Less than 50% of respondents, for example, agreed or strongly
agreed that they (or their team) had the training to undertake psychosocial
assessments of risk and need of people who had self-harmed (item (a)).
Overall, 25% of those in learning disability, 44% in rehabilitation, 47% in old
age, and 48% in general adult reported agreeing or strongly agreeing with
the statement (Table 8(a); www.rcpsych.ac.uk/risktoself).
T raining : underlying causes of self - harm

In Table 8(b), the large majority of psychiatrists reported agreeing or
strongly agreeing that they had been provided with the training to explore
with the patient the underlying causes of their self-harm (82.4%). This was
most evident in those working in academic settings (73%) or where their
psychiatric specialty was psychotherapy (92.1%). Only learning disability
reported a lower proportion (67.3%) (Table 8(b)).
R ole of psychiatrists
Table 8(c) indicates that the majority of respondents agreed or strongly
agreed that psychiatrists have a key role to play in the prevention of self-
harm (71%). More interesting perhaps is the number who disagree with
this view, including 11.3% of adult psychiatrists (67% thought otherwise)
compared with forensic and addiction psychiatrists, of whom 6% disagreed
but 85% agreed. This may reflect the different patient groups typically seen
by these consultants (www.rcpsych.ac.uk/risktoself).
E xpression of mental illness

In Table 8(d), 25% of respondents agreed or strongly agreed, 27% disagreed
or strongly disagreed, and 48% neither agreed nor disagreed with a
statement on whether self-harm was an expression of an underlying mental
illness.
Discharge
In Table 8(e), over a third of all participants agreed or strongly agreed
that discharge decisions about patients were being made by junior staff
with little training or experience. Sixty percent of those reporting that
rehabilitation was their main psychiatric specialty agreed or strongly agreed

Table 8 Listed below are a number of statements. Please indicate the strength with which you agree/disagree with each statement by
116
ticking the appropriate box (%)
(a) All health professionals in my team, (b) I have been provided (c) Psychiatrists (d) Self-harm is
including junior psychiatrists, social workers with the training and have a key role an expression
and psychiatric nurses, are properly trained knowledge to explore with to play in the of an underlying
in undertaking psychosocial assessments the patient the underlying prevention of self- mental illness
of risk and need for people who have self- causes of their self-harm harm
harmed
Strongly 3.9 1.8 1.5 3.9
disagree
Disagree 25.8 7.3 7.8 23.2
Neither 21.2 8.5 19.9 47.9
disagree/
agree
Agree 38.6 48.8 48.8 21.1
Strongly 10.4 33.6 22.0 3.9
agree
Base 1523 1530 1520 1523
Table 8 Listed below are a number of statements. Please indicate the strength with which you agree/disagree with each statement by
ticking the appropriate box (%)
(e) In terms of discharge of (f) In my organisation, (g) Services for (h) Harm minimisation
people who have self-harmed, psychological therapies management of repeated strategies for self-harm
decisions are often made by are available for people self-harm are lacking (excluding attempted
junior staff with little training who self-harm when this is outside of the immediate suicide) are a useful tool
or experience appropriate crisis
Strongly 9.1 5.9 4.3 1.4
disagree
Disagree 25.6 19.8 21.8 3.6
Neither 20.6 15.6 19.2 23.5
disagree/
agree
Agree 29.1 46.2 39.3 60.2
Strongly 5.7 12.6 15.4 11.3
agree
Base 1522 1521 1521 1527
http://www.rcpsych.ac.uk
Continued
Appendix I
with this statement, as did approximately forty-three per cent of those from
forensic, psychotherapy, liaison, and addictions settings (www.rcpsych.ac.uk/
risktoself).
P sychological therapies
In Table 8(f), the availability of psychological therapies gave a revealing
picture. In liaison, general adult, addictions, and learning disabilities 50–55%
of respondents agreed or strongly agreed with the statement that such
therapies were widely available in their organisation for people who self-
harmed. This compares with 73–78% of those respondents practising in child
and adolescent, psychotherapy and forensic settings (www.rcpsych.ac.uk/
risktoself).
Service provision
In Table 8(g) (whether services were available outside the immediate crisis),
more than half of all respondents (55%) agreed or strongly agreed that they
were.
H arm minimisation
Finally, over 70% of all respondents indicated that harm minimisation was a
useful strategy. Respondents in all main psychiatric settings except academic
settings had over 60% of participants agreeing or strongly agreeing with this
statement (Table 8(h); www.rcpsych.ac.uk/risktoself).
Section 3: Qualitative results

In this section, we present data based on responses from the 540
participants (35% of the total sample of 1540 respondents) who answered
the qualitative question:
‘The College is currently undertaking a comprehensive review of policy
and practice on self-harm. This will report back later in 2009. Do you
have any other issues would you like to see addressed by that review?
These can be general issues, or issues relating to your main psychiatric
specialty.’
Overview
In this report, we consider the ten most commonly cited themes by
respondents (Table 9).
For each of these themes we develop a typology to quantitatively
depict the range of opinion among participants. We also present extracts
of qualitative data to illustrate respondents’ opinions and views. However,
we open this report with a brief review of participants’ understandings and
conceptions of the term ‘self-harm’. This provides an insight into what the
term ‘self-harm’ means to those working in the field.

Table 9 Commonly cited themes

Citations, n Total sample, %
1. Roles and responsibilities 161 30
2. Training and education 128 24
3. Risk assessment tools 64 12
4. Age groups: children, adolescents and youth 62 11
5. Diagnostic groups: personality disorder 59 11
6. Services: A&E 58 11
7. Evidence and guidelines 58 11
8. Psychological therapies 54 10
9. Repeated self-harm 50 9
10. Services: liaison/general hospital 45 8
Results
P articipants’ definitions and concepts of self - harm ( citations : 98; cited
by 18% of sample )
Participants’ understandings and conceptions of the term ‘self-harm’ could
be broken down into four categories: underlying factors; mental disorder;
spectrum of conceptions; and negative conceptions.
Underlying factors
The majority of participants (in this category) raised concerns about
the potential medicalisation of self-harm, and the danger of overlooking
underlying social problems:
‘The problem is that self-harm is (very often) a “medical” end-point
to a social problem. Excluding those for whom major mental illness
is the cause of the self-harm, trying to find a medical solution to a
predominantly social problem will always be difficult.’ (ID 1494)
Participants in this category felt self-harm was not exclusively a health

problem. Although requiring psychiatrists’ professional input, it was seen as
requiring far greater involvement with agencies in the social care sector:
‘Self-harm should not be seen a being an exclusive mental health
problem, but part of a wider societal problem. Most patients who self-
harm do not have a serious mental illness, but often have poor coping
skills and poor social support.’ (ID 1409)
Mental disorder
A smaller number of participants, however, went further. Contending that
self-harm wasn’t a mental disorder, these participants observed it was
beyond the remit of psychiatric and mental health services:
‘Psychiatric services are NOT responsible for addressing or preventing
self-harm in general but for identifying and treating ... any MENTAL
DISORDER which is associated with self-harm. This may seem a pedantic
distinction but I believe that it is an honest and important one. Self-harm
is not a psychiatric disorder in its own right.’ (ID 1070)
Appendix I
Spectrum of conceptions
Other participants noted that conceptions and understandings of self-harm
used in everyday practice were broad, often resulting in difficulties or
inappropriate action. These participants called for a greater specificity in the
definition and use of the term.
‘The definition of self-harm was difficult. We get many referrals of sup
posed self-harm that we do not consider as such, e.g. children who poke
themselves with pencils. By your definition, children and young people
who take risks could be included – alcohol, staying out overnight ... over-
eating, food avoidance, unprotected sex, etc.’ (ID 1135)
‘Your definition of self-harm is rather too broad to be … useful in elderly

psychiatry, when there are so many ways people with dementia can
cause themselves harm.’ (ID 1165)
Negative conceptions
Some participants observed that self-harm was either perceived negatively
by health and social care professionals, or treated as synonymous with
personality disorder.
‘The main reason for “dislike” of self-harm patients is the impression
that they are a drain on scarce mental health resources and the
realisation [by the] professional that little is being achieved in terms of
improvement of their clinical condition.’ (ID 1102)
‘Self-harm is considered synonymous with ‘personality disorder’, often

with the term used in a derogatory and judgemental meaning.’ (ID
1390)
R oles and responsibilities ( citations : 161; cited by 30% of sample )

The roles and responsibilities of different professionals involved in working
with people who had self-harmed raised numerous concerns among
participants.
Self-harm: do psychiatrists have a role?
‘Yes – there is a central role.’
Participants in this category believed that psychiatrists had an important role

to play in relation to self-harm. As one participant noted, this was a core
part of their job:
‘… every patient I see gets a mental state exam, risk assessment, and
appropriate psychiatric history. I do not agree with the actuarial ‘paper-
pushing’ way that risk assessments seem to be taken out by CMHTs
– in my experience they give little clinical information of relevance.’ (ID
1200)
Others observed that the assessment of self-harm was part of

their role owing to the absence of skills among other professionals in the
multidisciplinary team:
‘As a psychiatrist I am often asked to do mental state examinations
on young people who display minor self-harm and am told “they are
suicidal” when they are clearly not but no one seems able other than
doctors to assess risk and consider safety.’ (ID 1372)

A small minority of psychiatrists, however, felt they should not have a

central role in dealing with self-harm. Some believed that self-harm was not
a mental disorder and therefore outside of the psychiatric remit (p. 118, ID
1070). Others pointed to psychiatric work being driven by risk rather than
clinical factors.
A small number of participants went even further, observing that the
intervention of psychiatrists in self-harm cases could make the situation
worse, rather than better.
‘Self-harm is a symptom not a disorder itself. Where self-harm exists
as part of a mental illness, then the illness should be treated. Where
there is no mental illness then this is not any business of psychiatry or
psychiatrists. We do harm by medicalising the stress of everyday life and
holding out a utopian view of happiness for all.’ (ID 821)
However, other participants took a more balanced approach, concluding

that work on self-harm was a role better led by other professional groups.
‘Psychiatrists should certainly not be seen as the only people who can
assess and help people [who self-harm]. I have found that focusing
training on well-motivated teams of people with strong links to the
voluntary sector, crisis teams, and an ability to communicate quickly and
effectively with primary care, available to say A&E departments and related
general hospital units is an effective way to raise standards.’ (ID 1180)
Risk assessment within the multidisciplinary team

Participants raised concerns about who undertook, and was responsible for,
risk assessments.
One group of participants identified assessment as a task for all
properly trained members of the multidisciplinary team.
‘[Assessment] does not necessarily have to be done by a psychiatrist,
but every psychiatrist should know how to carry out such assessments.’
(ID 1302)
This group included participants who pointed out that without

multidisciplinary team involvement, assessment solely undertaken by
psychiatrists would not be possible, and possibly even detrimental to patient
care.
‘There is pressure to provide urgent risk assessments for child and
adolescent patients 24 hours a day, 7 days a week in my NHS trust.
However, the most trained staff are psychiatrists, and there are not
enough of them to provide this kind of coverage without seriously
compromising other work that is more ongoing. This puts focus on crisis
rather than preventative work.’ (ID 589)
It was, however, noted that if every member of the multidisciplinary

team was potentially capable of undertaking assessments, clear guidance
was needed on who undertook assessments and in what situations:
‘… [we need] guidance on who can carry out assessments of risk/self-
harm in the immediate ‘aftermath’ or if this needs to be done by a
psychiatrist (my impression is that it does not in all cases, especially in
CAMHS ... but this may be warranted).’ (ID 1132)
However, there were concerns among a second strand of participants

about the potential consequences of the multidisciplinary team undertaking
assessments:
Appendix I
‘The self-harm team members (who are all non-medical staff) do … short
assessments, limit their questions to the self-harm pro formas while
assessing the self-harm cases and often overlook some common
psychiatric problems.’ (ID 1236)
‘Although patients who self-harm are well treated by A&E for their phys
ical problems (cuts, overdose, etc), there is almost never ANY attempt
to assess the mental state by A&E staff. The most that is written is “self-
harm, refer Psychs” or “Depressed, Psychs to see.” ALL doctors should be
able to do a basic assessment and mental state examination.’ (ID 1085)
Critically, this perspective was not a crude broad-brushed critique of

colleagues. Instead, it was nuanced in terms of the context in which the
service was being delivered:
‘There is increasing reliance on nursing staff to undertake risk
assessments for all patients (including those who self-harm). The needs
of the service often require that staff attend primarily to the “crisis
presentation”. This means that the emphasis is on the here and now
and not on how the person got to where they are and what might be the
consequences for them in the future. This means that any intervention
is necessarily short term and frequently opportunities to provide long-
term solutions are missed. This is partly related to nursing training, but
also to the high turnover expectation of acute mental health services
(particularly 4-hour waiting time targets in A&E settings).’ (ID 1237)
Trainee psychiatrists and self-harm

Many participants felt that a substantial burden was being placed upon
trainees to assess and deal with the majority of self-harm presentations, and
also make decisions about whether to discharge the patient:
‘I would estimate that 90% of the patients I saw out of hours were self-
harm.’ (ID 735)
This included concern that junior staff were not always adequately
supervised.
‘In my view many members of the multidisciplinary team are unaware of
their limitations in risk assessment and all too often such assessments
are carried out by my junior staff without ratification by more
experienced colleagues.’ (ID 1034)
Critically, such a burden on junior psychiatrists (including a lack of

appropriate supervision) also carried an accompanying risk for the patient:
‘I always have concerns that those individuals seen in A&E and sent
home are often assessed by the most junior staff. Often there are
protocols that all admissions must be discussed with senior staff, but
perhaps those at highest risk are those being sent home without having
been discussed with senior staff.’ (ID 1233)
There was also a concern that trainees were not being routinely
exposed to self-harm cases, and were therefore not obtaining skills to deal
with this:
‘I doubt that psychiatrists in training are receiving adequate properly
supervised clinical experience in assessing or treating such cases as
nurses now do much of this work, and their opportunities are reduced
by shorter working hours and other NHS cultural change (like 4-hour
A&E target).’ (ID 1396)

Some participants consequently called for interventions to overcome

this, including attention to training rotas to ensure junior doctors received
adequate exposure (and supervision) to cases of self-harm.
Risk management and the multidisciplinary team

The issue of assessments conducted by members of the multidisciplinary
team has been touched on above. However, many participants held the
view that there needs to be close collaboration across different professional
groups, particularly in relation to the management of self-harm after a risk
assessment had been conducted.
‘The recognition of self-harm for the illness behaviour that it is and that
policy and practice must include close collaborative working with the
A&E and surgical departments. In an ideal world, psychiatric nurses
work in the A&Es and have access to rapid therapeutic interventions with
separate teams within 48 hours of contact with A&E.’ (ID 1076)
Again, there were concerns about how much had been done to raise
the skills and confidence of professionals outside of psychiatry to undertake
such assessments:
‘... who all too often become complacent about actions of self-harm in
individuals who regularly repeat such acts. In my view many members
of the multidisciplinary team are unaware of their limitations in risk
assessment.’ (ID 1034)
Views also existed about whether those undertaking an assessment of

harm or risk were able to provide care to that patient.
‘There is an issue in the local service that those who assess self-harm
and risk are not necessarily in a position to implement their management
plan as there are other teams that determine admission to hospital or
choice of intervention. This limits the individual clinician in their ability
to manage self-harm.’ (ID 1203)
Other participants highlighted the importance of two key professional

groups: paediatricians and social workers. These were seen as key to
delivering effective care.
‘The consultation should talk to paediatricians as well as child
psychiatrists, as they are the ones responsible for admitting to paediatric
wards. Also maybe general physicians responsible for admitting 16- to
18-year-olds. This is often the point of conflict in some hospitals. Also
the consultation might want to look into the falling use of hospital
social workers. When I was an senior house officer in child psychiatry
we did all our ward deliberated self-harm assessments jointly with
the hospital social worker. Now we have to beg/pray to get the young
people assessed by Social Services before discharge & it only happens
in extreme child protection cases.’ (ID 1247)
Avoiding ownership of self-harm

Participants reported that some agencies often appeared to avoid taking
responsibility for the care of patients who self-harmed:
‘Other agencies which include social care and even child psychology
seem to worry so much about children self-harming and see it wrongly
as a risk of suicide and try and pass the patient as soon as possible
Appendix I
to CAHMS as a way of passing the buck as well as reducing their own

anxieties about the patient.’ (ID 1422)
Others reflected on similar experiences of agencies trying to avoid

ownership:
‘Acknowledgement and exploration of the dynamics between mental
health services and other services who have contact with people who
self-harm, in particular the A&E department. Frequent and ongoing
disagreements over who “owns” these patients can lead to a poor service
for this complex group.’ (ID 1389)
‘As a junior, I have found that nursing staff are obstructive to these
patients being admitted, particularly those who repeatedly self-harm
under the influence of alcohol. It is written in care plans not to admit
without discussing with the CMHT/intensive home treatment team.
However, these patients tend to present out of hours when there is just
a junior on-call with another consultant who doesn’t know the patient.
Often the nursing staff say “this is all alcohol” or “there isn’t a mental
illness”. As a junior, I feel quite unsupported. The phrase “Yeah well he/
she never does it [suicide], does she?” is the nursing staff’s justification
for being obstructive to admission. The culture in mental health nursing
must change, as should pejorative remarks or hints at “personality
disorder” because we can’t “cure” a patient.’ (ID 1110)
Resources
Throughout the consultation, participants repeatedly stated a common
problem with a lack of resources for providing services to people who have
self-harmed.
‘We currently lack the resources to offer follow-up to all who self-harm,
this especially is important for the repeaters. Repeated presentations to
A&E could also be addressed with sufficient multidisciplinary staffing.’
(ID 711)
It also spanned commentary on a lack of specific programmes or

professional types:
‘I have been trying for several years to point out to the local primary
care trusts that there is a strong evidence base for offering problem-
solving CBT as secondary prevention of self-harm. Yet there is no
implementation of this fairly well-proven treatment locally. This very
morning we were making the case to someone from the primary care
trust to employ a nurse therapist whose role would be to mobilise
primary care counsellors and IAPT to deliver problem-solving CBT for
people who have self-harmed once or twice already. No money available
for service developments apparently.’ (ID 1119)
Voluntary sector
A small number of participants commented on the activities of the voluntary
sector, with an underlying concern about the services provided to people
who self-harm.
‘Locally, third-sector services often offer services to people who
repeatedly self-harm, with and without a specific personality disorder,
either because they are offered no service in secondary care, or
because it is inadequate. The local third-sector services are not

specifically commissioned or trained to offer these services effectively.’

(ID 1122)
T raining and education ( citations : 128; cited by 24% of sample )

Training and education issues were cited in relation to four key areas.
Risk assessment training

Providing high-quality training in risk assessment was the most frequently
cited issue in this category, with most participants calling for further
investment in training to assess suicide risk and the assessment and
management of self-harm, especially repeat self-harm.
I think training in assessing suicide risk is poor … given that suicide is a
major cause of death among out-patients as compared to say the annual
training in CPR.’ (ID 485)
‘Psychiatrists should have compulsory training in learning how to deal

with (including the language to use, setting, things that can be helpful
to minimise distress in patient, etc) a patient who has self-harmed and
people who chronically self-harm.’ (ID 666)
Thinking about psychiatrists as a group, participants highlighted the

importance of providing training to junior doctors.
Junior doctors in training need more exposure to assessments of patients
who self-harm along with the crisis teams. Some trusts are excluding
these in order to make rotas European Working Time Directive and New
Deal compliant. This also helps to reduce bandings of junior doctors as
most of these assessments are done out of hours in A&E settings. This
I feel is depriving junior doctors of an important aspect of their training
and needs to be addressed on an urgent basis.’ (ID 964)
However, this was not just an issue for junior doctors, but also for non-
training grade psychiatrists.
‘I think it is important that whatever training there is on assessment and
management of self-harm it should be rolled out to both trainees and
non-training grade psychiatrists – they all see patients in this category.’
(ID 599)
There were, however, some who did not believe that training was the
central issue.
‘My training and that of other staff groups equips me to deal with self-
harm and risk assessment. Why are we so obsessed with the post-
modern idea of having to have a certificate or specific training module
for every aspect of our work. It devalues the wealth of experience that
most staff have already and makes people feel unskilled in providing the
services already on offer.’ (ID 836)
Training for other groups

Other participants drew attention to the need of other members of the
multidisciplinary team receiving training.
‘The review should address the training and competency of non-
psychiatrists who perform assessments – as John Tooke pointed out,
nurses in roles such as this frequently do not have any evidence of their
competency in this work.’ (ID 564)
Appendix I
‘Given the high prevalence of self-harm in adolescents I would like to

see more training of staff and services available to adolescents in school
settings.’ (ID 478)
‘A&E staff appear to have very little training in dealing with people who
self-harm (and ‘psychiatric’ presentations in general). They can come
across as angry/shouting and patronising to the patient, despite having
good intentions. It appears to be particularly difficult at times when A&E
is busiest.’ (ID 879)
Repeated self-harm
Specific observations were made about the need for training in relation
to repeated self-harm.
‘There needs to be comprehensive and “systemic” training of
adult in-patient ward staff in the management of repeated self-
harmers ... complemented by more availability of psychology/
psychotherapy support or, arguably, more consultant “time” available on
the wards to oversee/supervise staff in the management of these more
challenging cases.’ (ID 1225)
Training in the provision of psychological therapies was noted by several
participants.
‘Making sure that staff using psychological therapies in this area are
properly trained and not just deployed having had “taster” experiences
in various therapies, as I think this could be very harmful to patients
particularly in the long term.’ (ID 1027)
‘Evidence-based treatments like dialectical behaviour therapy should be

available to all. Training for such specialist therapy should be available to
professionals who are interested and all professionals should be trained
in principles of evidence-based treatments for self-harm. Self-harm is
considered to be challenging to manage owing to limited understanding
and thus avoidance by professionals, thus becoming an exclusion for
such individuals who need the most help.’ (ID 1141)
R isk assessment tools ( citations : 64; cited by 12% of sample )

Respondents cited ‘risk assessment’ as a key issue the College should
address. This covered the following issues: tools, limitations and resources.
Tools
A number of psychiatrists were interested in the development of a
standardised risk assessment tool, but were cautious of ‘tick box’
instruments. These were often seen as administrative or defensive tools
employed by their organisation.
‘Use of different risk assessment forms that are not validated and
yet exist for mandatory completion, irrespective of the setting or the
situation.’ (ID 1049)
‘I have a concern over the administration of self-harm and the

uninformed use of “rating scales”. Increasingly the filing of forms by
organisations is more important than thought in the management of
self-harm.’ (ID 1359)

However, some participants – often owing to organisational pressures

on time and resources, or simply the task of having to employ the range of
locally developed tools available – welcomed the development of such tools.
‘If the junior doctor is provided with an easy-to-follow proforma for
assessment, e.g. with tick boxes and circles, for the common questions,
it will save valuable time for doctors and the patients. At present
we cover multiple sites at night, including two A&Es, and are often
pressurised by the A&E staff.’ (ID 1217)
A small number of participants suggested providing greater support

to those who had to undertake assessments in the context of untoward and
serious events.
‘I think we also need to look at issues of reducing paper work and create
a system that is more proactively aiming to genuinely deal with self-harm
patients rather than getting drowned in paper work and making it a back
covering exercise to staff. There should be some new policy that could
provide assessors with some kind of protection in the eventuality of an
incident, so it could give them the independence to take decisions in the
best interests of the patients rather than them opting for the safer route
of admitting the patients who self-harm (as is often seen).’ (ID 1434)
Limitations
The limitations of the current organisation and undertaking of risk
assessment were highlighted by participants. These included concerns about
the utility of risk assessment tools, and the diminishment of professional skill
and judgement.
‘I think that the current emphasis of many services on risk assessment
is dangerous: an appreciation of the risks associated with an individual
can only be achieved by a more comprehensive psychosocial and needs
assessment. Unfortunately, many mental health services will only offer
a service to someone who is deemed to pose a “risk”. Such a policy is
discriminatory against people with mental health problems, and would
not be tolerated in a physical healthcare setting.’ (ID 1035)
Some participants identified the limitations placed on them by the

wider system in which they were working, including reduced access to in-
patient beds.
Resources
The majority of participants’ comments in this subcategory related to the
availability of resources to either allow staff to undertake detailed risk assess
ments, or for the implementation and follow-through of management plans.
Age groups – children , adolescents and youth ( citations 62, 11% of

all citations )
Participants’ comments covered admission, paediatrics, access and
assessment.
Admission
A number of participants identified issues relating to the admission of
children and young people.
Appendix I
‘I think it is crucial that young people under 16 are admitted to the

paediatric ward after self-harm. It gives a very powerful window of
opportunity to assess the situation in the cold light of day and away from
home circumstances.’ (ID 1099)
However, some participants pointed to the challenge of young people

admitted onto adult wards, and looked for the College to provide a clear
view.
‘According to our protocol, young people who are admitted onto
paediatric wards following self-harm have an overnight stay prior to
being assessed by CAMHS staff. Things are less clear for young people
admitted onto adult medical wards because the physicians want a faster
turnover and also adult psychiatrists have a different system and those
who self-harm can be seen almost immediately and discharged. This
leads to a bit of confusion and sometimes tension between ourselves
and physicians.’ (ID 1293)
Some participants, however, did not agree with this.

‘I go along with the caveat that everyone has to be admitted to allow
assessment, but I’m not sure I agree with it. Most people can make
rational choices, but this is an area where we don’t allow them choice.
I personally dislike the risk assessment culture that has been imported
from adult services. I think this has contributed to a risk-averse culture.
This has resulted in agencies trying to avoid responsibility, which reduces
the possibility of containing crises.’ (ID 955)
Others, meanwhile, pointed to resource limitations.

Finally, a number of participants wondered whether admission to
in-patient wards for young people might also be translated to adults
experiencing self-harm.
‘Admission to in-patient paediatric and general wards is very helpful to
carry out a psychosocial assessment as well as a risk assessment and
helps to liaise with the professionals that are most helpful. It reduces the
pressure on junior staff to make decisions in the night. Currently it is only
offered to young people under 16. I am, however, wondering whether
this system would be beneficial to people over 16 too.’ (ID 1224)
Paediatrics
The role of paediatric services and professionals was highlighted by eight
participants.
‘Paediatric staff and A&E staff need SOME mental health training, ability
to work with families, training on consent issues, Children Act, Mental
Health Act, etc., and to see deliberate self-harm in children as relevant to
their role … A great deal is written about the unsuitability of adult mental
health wards for children, but paediatric wards can also be unsuitable for
mentally ill/behaviourally disturbed children if their stay is prolonged and
paediatric staff do not see their presence on the ward as appropriate, or
treat them with less respect than their other patients. Difficulties arise
when it is unsafe to discharge a teenager to home and social services
are unable to accommodate them/offer support.’ (ID 1523)
Access
Access to services for children and young people was a commonly raised
issue, including specific reference to psychological therapies.

‘There are limited resources for 17- to 18-year-olds. We as a CAMHS

are underresourced to cover these areas. In CAMHS we do not have an
outreach crisis service, which makes follow-up of non-attenders very
hard. CAMHS are underresourced to cover recurrent harmers.’ (ID 502)
Assessment
The majority of comments made by participants are adequately covered in
Section 1 of this report. However, a number of additional observations were
made by participants, including:
‘... 16- to 18-year-olds service is a major issue, for example A&E
assessment by the appropriately qualified professionals, e.g. CAMHS
staff not available. Mental Health Act assessment for under-16s is not
easily available owing to lack of an approved mental health professional.
We have a plan and vision for a high-quality service but no extra
resources available to deliver it.’ (ID 1380)
Diagnostic groups – personality disorder ( citations 59, 11% of all

citations )
People living with personality disorder were a concern for participants, with
participant comments covering services and stigma and exclusion.
Services
Service provision for personality disorder was a key issue.
‘I think services are poor generally in thinking about and assessing
for personality disorder in repeated self-harm, and thereafter, if say
borderline personality disorder was identified, we have limited resources
locally for directing those people to get appropriate help.’ (ID 1122)
Services were also identified as lacking a long-term perspective to

care.
‘The necessary coordinated long-term care needed for people with
personality disorders is lacking or inadequate in all services in which
I have worked. Those with severe personality disorders may get
psychotherapy for periods of time but are unlikely to get long-term care-
coordination and team support. This often results in their care being
managed by a succession of junior doctors, resulting in over-medication.’
(ID 1279)
Stigma and exclusion

Discriminatory attitudes, or active discrimination, against people living with
personality disorder was highlighted by many participants.
‘There is a lack of understanding and training about self-harm; patients
are often labelled as “Just a personality disorder”, seen as manipulative
and not suffering from mental illness. These are the most stigmatised
group among our patients, seen as particularly demanding of services
and emotionally draining. Their care is often from crisis to crisis, with
very little understanding except from psychological services where I
work.’ (ID 1280)
Such attitudes were perceived by participants to be reflected in services

attitudes to taking on people with personality disorder who self-harmed.
Appendix I
‘Some psychiatrists do not see personality disorder as part of their remit,

resulting in some people not being allocated care coordinators because
‘there’s no work for them to do.’ (ID 794)
‘This group of patients take an awful lot of resources from all general
adult services and … a significant amount of clinical time … [from] other
patients for [whom] we feel more comfortable treating, or rather, have
more chances to help in the short-medium term.’ (ID 1308)
Services – A&E ( citations 58, 11% of all citations )

From the range of different service providers who featured in participants’
responses, A&E were the most commonly referred to.
Staff training
The majority of comments made by participants are adequately covered in
Section 2 of this report. However, a number of additional observations were
made.
‘Training of A&E nurses in self-harm assessment is important – in the
same way that psychiatry uses senior nurses to specialise in self-harm
assessment, the A&E nurses could train up senior staff to help with liaison
in A&E. More crisis services need to be set up that are not immediately
linked to doctors and nurses in psychiatry – this will get away from
repeatedly pathologising and biologicalising this patient group.’ (ID 1128)
‘Improved support/ education within A&E services – staff can be anxious,

become dispirited, leading to poor and inadequate assessment and
management. Support and supervision for junior staff. Attitudes within
A&E have improved greatly in past 10 years. Has contributed very much
to problems related to stigma.’ (ID 1395)
Assessment
Again, comments made by participants are covered in Section 1 of this
report. However, a number of additional observations provide interesting
detail.
‘It is variable, but often there is minimal information gathered by A&E/
ward staff with regard to risk and psychosocial assessment. Often
insufficient for them to make an informed decision about whether
the patient has the capacity to decide to leave the department before
assessment by a mental health practitioner has taken place. In this
particular hospital mental capacity in totality in reduced to a tick box of
whether or not they are “competent”. If faced with a patient who wants
to leave, the nurses often look in the notes and if competent is ticked
the patient is permitted to go home, even though no such assessment of
their capacity to make that particular decision at that time is assessed.
People with overt psychosis have been permitted to leave, without psych
assessment.’ (ID 1479)
‘The old and vexed issue of how to respond when called to A&E to a
non-psychotic patient who has taken an overdose and is now refusing
help; my own view is that this should be seen as a symptom of mental
disorder until proven otherwise through in-depth assessment, but with
the increasing profile of capacity issues every year, how hard will it be
to persuade A&E colleagues to treat in the patient’s best interests rather
than let them die?’ (ID 737)

Links with other services

The relationship between A&E and other services was pointed to.
‘The recognition of self-harm for the illness behaviour that it is and that
policy and practice must include close collaborative working with the A&E
and surgical departments. In an ideal world, psychiatric nurses work in
the A&E and have access to rapid therapeutic interventions with separate
teams within 48 hours of contact with A&E. So what I would like to
ask is: 1. To what extent are psych services responding to immediate
assessment in A&E and what skills do these assessors have? 2. What
is the patient pathway following assessment in A&E? 3. What lessons
can be learnt from the best outcome services? 4. What is the service
user/patient perspective and how is that gathered for this review?’ (ID
1076)
‘Even where good liaison psychiatry services exist, there still appears to
be a barrier integrating with accident and emergency. Having separate
general and mental health trusts exacerbates the problem. I would like
to see the mental health staff actually based (not visiting from separate
building or office) alongside A&E staff. At present there remains a culture
of ‘mental health’ problem, we’ll do our bit, stitch them up/parvolex,
then refer mental health, nothing more to do with us. Mental health staff
come as outsiders, often completing two sets of records.’ (ID 1487)
Discharge and follow-up

Discharge was identified as a particularly challenging period by many
participants.
‘The group of DSH individuals who can get missed is that of the self-
discharges from the emergency department – in our centre we have
developed a weekly review of such missed cases, and action is then
taken to follow them up or alert their GP or other involved in their care.’
(ID 1178)
‘I have lost count of the times I have reviewed a dead person’s notes to
see that after a suicide attempt they have been reviewed by someone
in A&E and ‘given a leaflet’ or a ‘telephone number’. (A recent report
into the Northwest crisis team numbers found that a third of patient
calls were met with no answer or an answerphone). The College MUST
highlight these problems more ... or else it will be seen as a complacent
accessory to these tragedies.’ (ID 1177)
Other participants identified the lack of follow-up to people who had

self-harmed as an area that needed to be addressed.
‘We used to be able to offer 1:1 follow-up to all self-harmers who came
to A&E often with the senior nurse who assessed them. This was a
good and well-used service and enabled more assessment time to see
whether further referral was necessary and also allowed brief focused
psychological work. The 4-hour targets in A&E and the need to provide
24-hour A&E nursing cover has now made this impossible and we offer
an inferior service with letter to GP to arrange follow-up, knowing that
this rarely happens. I feel having self-harm workers (specifically trained)
who can ensure links with primary care and also take on a case-load
to do short-term work would be very beneficial. Personally I think
such workers in a general hospital setting would be ideal to bridge the
gap between primary and secondary care. In my experience many GP
councillors do not feel they have the skills to take on – self-harmers. I
feel saddened at how little we can offer these patients unless they are
Appendix I
actively suicidal. The local CMHTs are not keen to have self-harmers
referred unless they are seen to have major underlying mental illness
or are very high risk. Local studies have shown GPs receiving a letter
to say somebody needs follow up arrange it in about 10% of cases! So
most of the people we see end up with nothing!’ (ID 1429)
E vidence and guidelines ( citations 58, 11% of all citations )

The existence of supporting evidence for policy and practice recommendations
was a key concern for many participants. Some, interestingly, also called for
clarification of statements made in evidence-based guidelines, such as those
produced by NICE.
Supporting evidence
There was often strong concern about programmes or practice interventions
being recommended in the absence of supporting evidence.
‘I think the College should do something about stopping people from
making recommendations about practice in the absence of proper
scientific evidence that the recommendations are effective, or worse,
when the evidence shows they are ineffective. I try to treat my patients
with kindness and humanity, and to make them feel they matter – and
that takes a lot of time – and I’m a bit fed up being told to follow policies
that are ill thought out or introduced for political reasons, sometimes
by people who either lack training in scientific method, or who should
know better.’ (ID 1503)
Other participants pointed to specific aspects of NICE and other

guidelines lacking supporting evidence. For example, as two participants
noted:
‘NICE guidelines for the management of self-harm in children and young
people recommend an intervention for repeated self-harm for which
there is no evidence base (developmental group therapy). This needs to
be urgently revised.’ (ID 472)
‘NICE talks about dialectical behaviour therapy – I think there should

be a review of evidence for this therapy and a specific statement made
about who would benefit from this approach.’ (ID 500)
P sychological therapies ( citations 54, 10% of all citations )

Access to psychological therapies among people who self-harmed was
commonly referred to among participants, covering access and staffing and
experience.
Access
‘I left my previous post … because services we had developed locally
for people with self-harm were dismantled by the Trust Executive and
psychological services to free up staff to undertake IAPT. A good skill
base and success rate was wiped out by stupid managers without any
consultation.’ (ID 525)
Staffing and experience

‘Rather than yet another policy we need more senior staff with
appropriate time, psychotherapy AND psychiatry or psychology training

as well as sufficient medium-term crisis services. The latter ones are

unfortunately far too often staffed with inexperienced colleagues, and
these crisis resolution teams rarely provide an extended assessment and
if indicated short- to medium-term treatment.’ (ID 1485)
R epeated self - harm ( citations 50, 9% of all citations )

Individuals who repeatedly self-harmed were identified as a group that
needed additional services and intervention and training support.
Services
‘There is much that can be done to assist [people who repeatedly
self-harm] but there is no investment or money available to create a
specialist service for them. If an age-inclusive service with the aim
of early education and support could be developed (i.e. like the early
intervention service), then the significant costs to the service overall
would be reduced. This will not occur in any meaningful way without
“priming the pump” with an initial investment, which in this current
climate is unlikely to happen.’ (ID 1017)
Training
‘I feel we need more training on management of repeat serious self-
harmers. I do not feel that there is enough support for people who self-
harm, often they are excluded from secondary care support as the belief
is that we make them worse, and I am not sure where the evidence for
this actually comes from to inform this general belief.’ (ID 1240)
Services – liaison / general hospital ( citations 45, 8% of all citations )

Participants presented a range of views about psychiatric liaison services,
and links with the general hospital setting. These were organised around
issues of better service provision and addressing poor levels of funding.
Need better commissioning of liaison psychiatry services – and ensure
that mental health trusts understand these are not the same as a crisis
team (especially if the crisis team function on Department of Health
crisis resolution home treatment criteria where SMI is needed). Need to
ensure a service limited to self-harm assessment in an acute hospital
will also cover acute hospital wards, orthopaedics, intensive care, etc.,
in addition to A&E.’ (ID 1091)
‘The decline and closure of comprehensive liaison psychiatry services.’

(ID 1206)
Appendix II: People who gave
evidence to the Working Group
Dr Donald Campbell Senior Honorary Consultant, Portman Clinic
Dr Alys Cole-King Consultant Liaison Psychiatrist, Wrexham Maelor

Hospital
Mr Patrick Daniels Advice and Volunteering Manager, YouthNet
Ms Margaret Edwards Head of Strategy, SANE
Mr Joe Ferns Acting Director of Policy Research and

Development, Samaritans
Professor Elspeth Guthrie Honorary Professor of Psychological Medicine,

University of Manchester; Chair of the Liaison
Faculty of the Royal College of Psychiatrists
Dr Robert Hale Consultant Psychotherapist and Psychoanalyst,

Portman Clinic
Professor Keith Hawton* Consultant Psychiatrist, Professor of Psychiatry

at Oxford University, Director Oxford Centre for
Suicide Research
Dr Fiona Mason Consultant Forensic Psychiatrist, Associate

Medical Director for Services for Women and
Consultancy Service
Mr Dougie Paterson* Programme Manager, Choose Life
Mr Gavin Peake-Jones Director, Consultancy Services, Open Minds
Professor Stephen Platt* Professor of Health Policy Research, Director

of the Research Unit in Health, Behaviour and
Change
Dr Marcus Roberts Director of Policy, DrugScope
*Separate meeting with Rowena Daw and Martin Skipper.

Professor George Consultant Psychiatrist, Professor of Psychiatry

Szmukler and Society, Institute of Psychiatry, London
Jim Valentine Communities Manager, YouthNet
Ms Marjorie Wallace Chief Executive, SANE
Ms Sue Waterhouse Leader on Women and Gender, National

Gender Equality Lead at National Mental
Health Development Unit
Consultations and other evidence received from individuals
Mr Naheen Ali Member of Service User Forum, Royal College

of Psychiatrists
Ms Lesley Bell Turning Point
Professor Kam Bhui Professor of Cultural Psychiatry and

Epidemiology and Honorary Consultant
Psychiatrist, Barts and the London School
of Medicine & Dentistry
Dr Peter Byrne Consultant Liaison Psychiatrist, Senior Lecturer

in Psychiatry at University College London
Professor Carolyn Professor of Primary Care, University of

Chew-Graham Manchester, Royal College of General
Practitioners Clinical Champion for Mental
Health
Ms Christine Cartin Turning Point
Professor Linda Gask Professor of Primary Care Psychiatry, University

of Manchester
Mr Willian Gore Public Affairs Director, Press Complaints

Commission
Professor Riaz Hassan Emeritus Professor in the Department of

Sociology, Flinders University in Adelaide,
Australian Research Council Professorial Fellow
Mr Ian Hulatt Mental Health Adviser, Royal College of Nursing
Dr James Johnston Consultant Psychiatrist in Psychotherapy,

Leeds University
Ms Mary Nettle Mental health user consultant
DrugScope
Samaritans
Young Minds
Contextual factors
1. Cultural factors Suicidal behaviour
2. Institutional settings (suicide, suicide attempts, deliberate
3. Media climate self-harm, suicidal ideation)
4. Physical environment

Mental health problems
behaviour
(e.g. mood disorders, substance use
disorders, antisocial behaviour/dis-
orders, anxiety disorders, psychotic
disorders, eating disorders
Individual Family factors Social supports Cultural factors

factors (e.g. parental (e.g. social isolation, (e.g. extent of ac-
(e.g. personality, separation, mental living alone) culturations, integra-
genes) illness) tion, autonomy,
language, identity)
Exposure to Life events Socioeconomic Mental health

trauma (e.g. marital/legal/ factors problems
(e.g. family vio- financial problems, (e.g. income, (e.g. economic
lence, child abuse, unemployment, education, housing, restructuring, birth,
bulling) discrimination) mobility) divorce, unemploy-
ment rates)
Appendix III: Pathways to suicide
135
Self-harm,

suicide and risk:
helping people
who self-harm
Self-harm, suicide and risk: helping people who self-harm

© 2010 Royal College of Psychiatrists

Cover photograph: © 2010 iStockphoto/Natalya Filimonova
College Reports have been approved by a meeting of the Central Policy Coordination Committee and
constitute College policy until they are revised or withdrawn.
For full details of reports available and how to obtain them, contact the Book Sales Assistant at the Royal
College of Psychiatrists, 17 Belgrave Square, London SW1X 8PG (tel. 020 7235 2351, fax 020 7245 1231). Royal College of Psychiatrists
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Scotland (SC038369). College Report CR158

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Self-harm,

Royal College of Psychiatrists

Self-harm, suicide and risk: helping people who self-harm

© 2010 Royal College of Psychiatrists

Final report of a working group

College Report CR158

Royal College of Psychiatrists

Royal College of Psychiatrists 3

Self-harm is poorly understood in society even among those who in their

Royal College of Psychiatrists 5

The report is divided into three parts. In Part I, we give some

Part I: Understanding the problems and the people

Part II: The public health agenda

Royal College of Psychiatrists 7

In Part II of the report we also mention the important role of other

Part III: Working with individual people

Respondents to the College survey expressed dissatisfaction with the

Royal College of Psychiatrists 9

Support for staff

Royal College of Psychiatrists 11

Discharge and continuity of care

Particular groups of people

A perceived neglect for people who repeatedly harm themselves and

Given the ageing population and the previous comparative neglect

The third sector

Royal College of Psychiatrists 13

Appendix I gives a summarised account of the findings of the College

Royal College of Psychiatrists 17

College Members’ survey

Structure of the report

Previous related College Reports

Royal College of Psychiatrists 19

Psychiatrists, the Faculty of Accident and Emergency Medicine, and

The service users’ National Self-Harm Network (NSHN; 1998)

Some of the people consulted as part of this report expressed their

Royal College of Psychiatrists 21

Incidence in different age groups and gender issues

Motives and causes

An act of self-harm is often described by service users as a coping

In a study of people who self-injure and have a diagnosis of borderline

Royal College of Psychiatrists 23

Similar motivation has been expressed in studies across different

Self-harm can also have a contagious effect, particularly with young

‘Self-harm is not an illness, but is more or less dangerous behaviour that

As yet we have not mentioned formal psychiatric illness regarding self-

Royal College of Psychiatrists 25

People with intellectual disabilities

They indicated the circumstances leading to their self-harm. These

Drug and alcohol issues and dual diagnosis

Royal College of Psychiatrists 27

Self-harm and physical health

There is, as one respondent put it, a danger of ‘overmedicalising

Dr Roberts from DrugScope described the complex issues that may

Royal College of Psychiatrists 29

‘Where someone is, for example, homeless, with a history of mental

Self-harm occurs in people of all ages but unsurprisingly rates of self-

Some precipitating and protective factors for suicide

Different age groups

Royal College of Psychiatrists 31

Groups of people at particular risk of self-harm

The WHO’s Health in Prisons project listed negative factors in prisons

Other environmental factors that have been linked to an increased

Women prisoners and self-harm

mapping and assessing existing training provision and projects across

Prospective and case–control research studies of self-harm in the